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Draft Application Forms

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United States Environmental Protection Agency Office of Water Washington, D.C. EPA Form 3510-2A

Revised <INSERT DATE>



### Water Permits Division 

# Application Form 2A

New and Existing Publicly

Owned Treatment Works

NPDES Permitting Program

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

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

This document is being distributed fo r comment purposes only. Comments and suggestions regarding this draft document should be submitted through electronic comments to http://www.regulations.gov.

### Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation



### Paperwork Reduction Act Notice

The U.S. Environmental Protection Agency estimate s the average burden to collect information and complete Form 2A to average between 5 and 25 hours, depending on the number of sections the applicant must complete. The estimate includes time for reviewing instructions , searching existing data sources, gathering and maintaining the needed data , and completing and reviewing the collection of information. Send comments regarding the burden estim ate 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 17 th 

### Street, NW, Washington, DC 20503,

marked “Attention: Desk Officer for EPA.”2A-1 

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FORM 2A

— GENERAL INSTRUCTIONS

Who Must Complete Form 2A?

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

At the state level, either the U.S. Environmental Protection Agency (EPA) or an approved state agency operates the NPDES permit program. If you are located in a jurisdiction in which an EPA regional office administers the NPDES permit program, you should use Form 2A and all other applicable forms described in these instructions. If you are located in a jurisdiction where a state administers the NPDES permit program, contact the state to determine the forms you should complete. Often states develop their own application forms rather than use the federal forms. See http://www.epa.gov/npdes/npdes-state-program-information for a list of states that have approved NPDES permit programs and

those that do not.

Exhibit 2A

– 1 (see end of this section) provides contact information
for each of EPA’s 10 regional offices. Since the content of Exhibit

2A

– 1 is subject to change, consult EPA’s website for the latest

information: http://www.epa.gov/aboutepa#regional

. Where to File Your Completed Form

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

forms.

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

Exhibit 2A

– 1).

When to File Your Completed Form

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

later date.

Fees

EPA does not require applicants to pay a fee for applying for NPDES permits. However, states that administer the NPDES permit program may charge fees. Consult wi th state officials for further

information.

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. You may not claim any information on Form 2A (or related attachments) as confidential. You may make a claim of confidentiality for any information that you submit to EPA that goes beyond the information required by Form 2A. If you do not assert a claim of confidentiality at the time you submit your information to the NPDES permitting authority, EPA may make the information available to the public without further notice to you. EPA will handle claims of confidentiality in accordance with the Agency’s business confidentiality regulations

at Part 2 of Title 4 of the Code of Federal Regulations (CFR).

Completion of Forms

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

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

form.

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

– 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.

Note for New Dischargers

Provide all information available to you at the time you complete Form 2A. If you do not have information to respond to a particular item, because your facility has yet to discharge, write or type “data are not available” next to the item on the form. Note that you are required to submit actual data no later than 18 months after your facility commences to discharge.

The NPDES permitting authority w ill consider your application complete when it and any supplementary material are received and completed according to the authority’s satisfaction. The NPDES permitting authority will judge the completeness of any application independently of the status of any other permit application or permit for the same facility or activity.

Definitions

All significant terms used in Form 2A are included in the “Glossary”

located at the end of these Instructions.2A-2 

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FORM 2A

— GENERAL INSTRUCTIONS CONTINUED

Exhibit 2A

– 1. Addresses of EPA Regional Contacts and Covered States

REGION 1

U.S. Environmental Prot ection Agency, Region 1 5 Post Office Square, Suite 100, Boston, MA 02109-3912. Phone: (617) 918-1111, Fax: (617) 918-0101, Toll fr ee within Region 1: (888) 372-7341

Website: http://www.epa.gov/aboutepa/ epa-region-1-new-england Covered States: Connecticut, Maine, Massachusetts, New Hampshire, Rhode
Island, and Vermont REGION 6

U.S. Environmental Prot ection Agency, Region 6
1445 Ross Avenue, Suite 1200, Dallas, TX 75202-2733 Phone: (214) 665-2200, Fax: (214) 665-7113, Toll fr ee within Region 6: (800) 887-6063

Website: http://www.epa.gov/aboutepa/epa -region-6-south-central
Covered States: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas

REGION 2

U.S. Environmental Prot ection Agency, Region 2 290 Broadway, New York, NY 10007-1866 Phone: (212) 637-3000, Fax: (212) 637-3526, Toll fr ee within Region 2: (877) 251-4575

Website: http://www.epa.gov/aboutepa/epa-region-2 Covered States: New Jersey, New York, Virgin Islands, and Puerto Rico REGION 7

U.S. Environmental Prot ection Agency, Region 7
11201 Renner Boulevard, Lenexa, KS 66219 Phone: (913) 551-7003, Toll free: (800) 223-0425

Website: http://www.epa.gov/aboutepa/epa-region-7-midwest

Covered States: Iowa, Kansas, Missouri, and Nebraska

REGION 3

U.S. Environmental Prot ection Agency, Region 3
1650 Arch Street, Ph iladelphia, PA 19103-2029 Phone: (215) 814-5000, Fax: (215) 814-5103, To ll free: (800) 438-2474

Website: : http://www.epa.gov/aboutepa/ epa-region-3-mid-atlantic
Covered States: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia REGION 8

U.S. Environmental Prot ection Agency, Region 8 1595 Wynkoop Street, Denver, CO 80202-1129 Phone: (303) 312-6312, Fax: (303) 312-6339, To ll free: (800) 227-8917

Website: http://www.epa.gov/aboutepa/epa-r egion-8-mountai ns-and-plains
Covered States: Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming

REGION 4

U.S. Environmental Prot ection Agency, Region 4

Sam Nunn Atlanta Federal Center 61 Forsyth Street, SW, Atlanta, GA 30303-8960 Phone: (404) 562-9900, Fax: (404) 562-8174, To ll free: (800) 241-1754

Website: http://www.epa.gov/aboutepa/a bout-epa-region-4-southeast Covered States: Alabama, Florida, Georgia, Kentucky, Mississippi, North
Carolina, South Carolina, and Tennessee REGION 9

U.S. Environmental Prot ection Agency, Region 9
75 Hawthorne Street, San Francisco, CA 94105 Phone: (415) 947-8000, Fax: (415) 947-3553, Toll fr ee within Region 9: (866) EPA-WEST

Website: http://www.epa.gov/aboutepa/epa-region-9-pacific-southwest

Covered States: Arizona, California, Ha waii, Nevada, Guam, American Samoa,

and Trust Territories

REGION 5

U.S. Environmental Prot ection Agency, Region 5 77 West Jackson Boulevard, Chicago, IL 60604-3507 Phone: (312) 353-2000, Fax: (312) 353-4135, Toll fr ee within Region 5: (800) 621-8431

Website: http://www.epa.gov/aboutepa/epa-region-5

Covered States: Illinois, Indiana, Mi chigan, Minnesota, Ohio, and Wisconsin REGION 10

U.S. Environmental Prot ection Agency, Region 10
1200 Sixth Avenue, Suite 900, Seattle, WA 98101 Phone: (206) 553-1200, Fax: (206) 553-2955, To ll free: (800) 424-4372

Website: http://www.epa.gov/aboutepa/epa -region-10-pacific-northwest Covered States: Alaska, Idaho, Oregon, and Washington2A-3 

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FORM 2A

— LINE-BY-LINE INSTRUCTIONS

Section 1. Basic Application Information for All Applicants

Facility Information

Item 1.1. Enter the facility’s official or legal name. Do not use a colloquial name. Provide the mailing add r ess of the facility. Next, give the name (first and last), title, work telephone number and electronic mail (email) address of the person who is thoroughly familiar with the operation of the facility and with the facts reported in this application.

Include a complete location address for the facility if different from the mailing address. If the facility lacks a street name or route number, give the most accurate, alternative geographic information (e.g., section number or quarter section number from county records or “at intersection of Routes 425 and 22”).

Provide the latitude and longitude to the nearest second for the facility. Provide associated metadata in the subsequent columns of
the table. In the column marked “Reference Point,” indicate where the coordinates were collected (e.g., from the main entrance of the facility or the center of the facility). In the column marked “Collection Method Information,” indicate the following: (1) 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, State Plane Coordinate System or SPCS, etc.); (2) the 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 (3) the 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., Terra Server or Google Earth), or paper maps from trusted sources (e.g., U.S. Geological Survey or USGS) to identify

coordinates. The online services r equire that you enter a property address, the nearest intersection, or ZIP code. The system then generates the coordinates. The horizontal collection method for such sources is “Interpolation—Satellite.” You would not report a source map scale if you used a GPS device or one of the online systems. For the horizontal reference datum, you would report one of the following three options:

1. North American Datum of 1927 (NAD27): This datum was based on the ground survey in Europe and North America in

the 19 th

century. NAD27 was the standard for many years because the USGS published its topographic maps in this datum. If you are reporting a location using a USGS 7.5- minute map, NAD27 is your default datum.

2. North American Datum of 1983 (NAD83): NAD83 updated NAD27 with current measurements using radio astronomy and satellite observations. When the USGS began publishing digital data, the NAD83 was used, which provided a more accurate representation of the earth’s shape and a more accurate depiction of the location of objects on the earth.

3. World Geodetic System of 1984 (WGS84): This datum was developed from the measurements calculated in NAD83. If you used a GPS to calculate your latitude/longitude coordinates,

WGS84 is the default datum.

If you need further guidance in responding to Item 2.6, refer to http://www.epa.gov/geospatial/latitudelongitude-data-standard

.

Item 1.2. Indicate whether the application is for a facility that has not yet commenced discharge. If “yes,” be advised that you are required to submit actual data no later than 18 months after your facility commences to discharge.

Applicant Information

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

Item 1.4. Indicate if the applicant is the facility’s owner, operator, or

both.

Item 1.5. Specify whether the NPDES permitting authority should send correspondence to the facility or the applicant.

Existing Environmental Permits

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

Collection System and Population Served

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

Do not report privately owned collection systems discharging

industrial waste to the treatment works in Item 1.7. Those facilities must be reported on Table F.

Indian Country

Item 1.8. Indicate if the POTW is located in Indian Country.

Item 1.9. Note whether the treatment works discharges to a receiving stream that flows through Indian Country.

Design and Actual Flow Rates

Item 1.10. Provide the facility’s design flow rate in million gallons per day (mgd). Next, specify the facility’s actual annual average daily flow rate and maximum daily flow rate for each of the previous three years (in mgd).

Discharge Points by Type

Item 1.11. Provide the facility’s total number of effluent discharge points to waters of the United States by type (e.g., treated effluent, untreated effluent, combined sewer overflows, bypasses, and constructed emergency overflows).

Outfalls and Other Discharge or Disposal Methods

Outfalls Other Than to Waters of the United States

Item 1.12. Indicate whether the POTW discharges wastewater to basins, ponds, or other surface impoundments that do not have outlets for discharge to waters of the United States. If “yes,”

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— LINE-BY-LINE INSTRUCTIONS CONTINUED

continue to Item 1.13. If “no,” skip to Item 1.14.

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

intermittent.

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

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

Item 1.16. Note whether the facility’s effluent is transported to another facility for treatment prior to discharge. If “yes,” continue to Item 1.17. If “no,” skip to Item 1.21.

Item 1.17. Describe the means by which the effluent is transported, such as by tank truck or pipe.

Item 1.18. Specify whether the facility’s effluent is transported by a party other than the applicant. If “yes,” continue to Item 1.19. If “no,” skip to Item 1.20.

Item 1.19. Provide the name, mailing address, contact person, phone number, and email address of the entity that transports the discharge.

Item 1.20. Provide the name, mailing address, contact person, phone number, email address, NPDES permit number (if any) of the receiving facility. Also specify the average daily flow rate from the facility into the receiving facility in mgd.

Item 1.21. Indicate if wastewater is disposed to places/structures (other than those already mentioned in Items 1.14 through 1.21)

that do not have outlets to waters of the United States, such as underground percolation and underground injections. If “yes,” continue to Item 1.22. If “no,” skip to Item 1.23.

Item 1.22. Provide a description of the disposal method, including the location and size of each disposal site; the annual average daily discharge volume (in gpd), and indication of whether disposal through this method is continuous or intermittent.

Contractor Information

Item 1.23. Indicate if any of the operational or maintenance (O&M) activities associated with wastewater treatment and effluent quality of the POTW are the responsibility of a contractor. If “yes,” continue to Item 1.25. If “no,” skip to Section 2.

Item 1.24. Provide a listing of all contractors (by company name). For each, specify the mailing address, a contact name, telephone
number, and email address. Also summarize the O&M responsibilities of each contractor.

Section 2. Additional Information

Outfalls to Waters of the United States

Design Flow

Item 2.1. Indicate whether the treatment works has a design flow greater than or equal to 0.1 mgd? If “yes,” continue to Item 2.2. If “no,” skip to Section 3. Inflow and Infiltration

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

minimize inflow and infiltration.

Topographic Map

Item 2.3. Prepare a topographic map (or other map if a topographic map is unavailable) extending at least one mile beyond property boundaries of the treatment plant, including all unit processes, and showing the following: (a) treatment plant area and unit processes; (b) major pipes or other structures through which wastewater enters the treatment plant and the pipes or other structures through which treated wastewater is discharged from the treatment plant (include outfalls from bypass piping, if applicable); (c) each well where fluids from the treatment plant are injected underground; (d) wells, springs, and other surface water bodies listed in public records or otherwise known to the applicant within 1⁄4 mile of the treatment works’ property boundaries; (e) sewage sludge management facilities (including on-site treatment, storage, and disposal sites); and (f) location at which waste classified as hazardous under the Resource Conservation and Recovery Act (RCRA) enters the treatment plant by truck, rail, or dedicated pipe.

On each map, include the map scale, a meridian arrow showing north, and latitude and longitude to the nearest second. On all maps of rivers, show the direction of the current. In tidal waters, show the directions of ebb and flow tides. You may develop your map by going to the USGS’s National Map website at http://nationalmap.gov/ . Use the traditional 7.5-minute quadrangle format. If none is available, you may use a USGS 15-minute series map. You may also use a plat or other appropriate map. Briefly describe land uses in the map area (e.g., residential, commercial, etc.). Answer “yes” to Item 2.3 once you have completed and attached your topographic map to the application.

Flow Diagram

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

Scheduled Improvements and Schedules of Implementation

Item 2.5. Indicate whether any improvements to the facility are scheduled. If “yes”, list and briefly describe each scheduled improvement and continue to Item 2.6. If “no”, skip to Section 3.

Item 2.6. For each scheduled improvement, indicate the outfall

number of each outfall affected and the scheduled or actual dates of completion for the following: (a) commencement of construction, (b) completion of construction, (c) commencement of discharge, and (d) attainment of operational level.2A-5 

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— LINE-BY-LINE INSTRUCTIONS CONTINUED

Item 2.7. Note whether the appropriate permits/clearances concerning other federal/state requirements have been obtained and briefly explain your response.

Section 3. Information on Effluent Discharges

Description of Outfalls

Item 3.1. Provide a description of each of the POTW’s wastewater discharge outfalls. The application form provides reporting space for three outfalls. If your facility has more than this number, attach additional sheets as necessary.

For each outfall, provide the outfall number. Indicate the state, county, and city or town where each outfall is located. Note the distance from shore in feet and the depth below the surface in feet. Specify the average daily flow rate through the outfall in mgd. Also specify the latitude and longitude of each outfall to the nearest second and associated metadata (e.g., horizontal collection method, scale of source map or photo, if applicable, and horizontal reference datum). 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. (See Line-By-Line Instructions to Item 1.1 for guidance on supplying method of collection information.)

Seasonal or Periodic Discharge Data

Item 3.2. Indicate whether any of the outfalls described under Item 3.1 have seasonal or periodic discharges. If “yes,” continue to Item 3.3. If “no”, skip to Item 3.4.

Item 3.3. Specify the following for each applicable outfall: (a) number of times per year discharge occurs, (b) average duration of each discharge, (c) average flow of each discharge in mgd, and (d) months in which discharge occurs.

Diffuser Type

Item 3.4. Note whether any of the outfalls listed under Item 3.1 are equipped with a diffuser. If “yes” continue to Item 3.5. If “no,” skip to

Item 3.6.

Item 3.5. Briefly describe the diffuser type at each applicable

outfall.

Waters of the United States

Item 3.6. Note whether the POTW discharges or plans to discharge

wastewater to waters of the United States from one or more discharge points. If “yes,” continue to Item 3.7. If “no,” skip to

Section 6.

Receiving Water Description

Item 3.7. Provide receiving water and related information in the table provided on the form (if known): (a) name of receiving water; (b) name of watershed / river / stream system; (c) U.S. Soil Conservation Service 14-digit watershed code; (d) name of state management / river basin; (e) USGS 8-digit hydrologic unit code (HUC); (f) acute critical low flow in cubic feet per second (cfs); (g) chronic critical low flow in cfs; and (h) total hardness of receiving stream at critical low flow (in m illigrams per liter (mg/L) of calcium carbonate), if applicable. Treatment Description

Item 3.8. Specify the highest level of treatment provided for discharges from each outfall (e.g., primary, equivalent to secondary, secondary, or advanced). Also indicate the following design removals (in percent) for the following parameters for each outfall: (a) biochemical oxygen demand (BOD 5 or CBOD 5 ), (b) suspended solids (TSS), (c) phosphorus (if applicable), (d) nitrogen (if applicable), and (e) any other removals that an advanced treatment system is designed to achieve.

Item 3.9. Provide a description of the type(s) of disinfection used for wastewater discharged through each outfall. Indicate the seasons the disinfection type is used. Note whether the POTW dechlorinates if disinfection is accomplished through chlorination. Otherwise, check “Not Applicable.”

Effluent Testing Data and Tables A through E

Items 3.10 to 3.26. These items require you to collect and report data for the parameters and pollutants listed in Tables A through E, located at the end of Form 2A. The instructions for completing the tables are table-specific in addit ion to the criteria for determining who should complete them.

IMPORTANT NOTE: Read the “General Instructions for Reporting, Sampling, and Analysis” later in these Instructions before completing Items 3.10 to 3.26 and Tables A through E.

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

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

Item 3.12. For each applicable outfall, note the number of acute and chronic WET tests conducted since the last permit reissuance of the facility’s discharges or of the receiving water near the discharge points.

Item 3.13. Note whether the POTW has a design flow greater than or equal to 0.1 mgd. If “yes,” continue to Item 3.14. If “no,” skip to

Item 3.16.

Item 3.14 and Table B. Answer whether the treatment works uses chlorine for disinfection, uses it elsewhere in the treatment process, or otherwise has reasonable potential to discharge chlorine in its effluent. If “yes,” complete Table B including chlorine. If “no,” complete Table B, omitting chlorine.

Item 3.15. Answer “yes” when you have completed monitoring for all applicable Table B parameters and attached the results to your application.

Item 3.16 and Screen for Tables C through E. Indicate whether one or more of the following conditions apply to your POTW:

 The facility has a design flow ≥ 1 mgd.

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FORM 2A

— LINE-BY-LINE INSTRUCTIONS CONTINUED

 The POTW has an approved pret reatment program or is required to develop such a program.

 The NPDES permitting authority has notified the facility that it must sample for the parameters in Table C, sample for additional parameters (Table D), or submit the results of WET tests for acute or chronic toxicity for each of the facility’s discharge outfalls (Table E).

If “yes,” continue to Item 3.17. If “no,” skip to Section 4.

Item 3.17 and Table C. Answer “yes” to indicate you have completed monitoring for all applicable Table C pollutants and attached the results to your application package.

Item 3.18 and Table D. Answer “yes” to indicate you have completed monitoring for applicable Table D pollutants required by your NPDES permitting authority and attached the results to your application package, or “no” if the NPDES permitting authority has not required additional sampling for the pollutants in Table D.

Item 3.19 and Additional Screen for Table E. Answer whether the POTW conducted either (a) a minimum of four quarterly WET tests for one year preceding this permit application or (b) at least four annual WET tests in the past 4.5 years. If “yes,” continue to Item 3.20. If “no,” complete tests and Table E and then skip to Item 3.26.

Item 3.20 and Additional Screen for Table E. Report whether you have previously submitted the results of the WET tests indicated in Item 3.19 to your NPDES permitting authority? If “yes,” continue to Item 3.21. If “no,” provide the results in Table E and skip to Item

3.26.

Item 3.21. Report the dates the testing data were submitted to your NPDES permitting authority and provide a summary of the results.

Item 3.22. Regardless of how you may have provided the results of previously conducted WET analyses to your NPDES permitting authority, indicate if any of the tests resulted in toxicity? If “yes,” continue to Item 3.23. If “no,” skip to Item 3.26.

Item 3.23. Describe the cause(s) of toxicity.

Item 3.24. Indicate if the POTW has conducted a Toxicity Reduction Evaluation. If “yes,” continue to Item 3.25. If “no,” skip to

Item 3.26.

Item 3.25. Provide details of any Toxicity Reduction Evaluations performed.

Item 3.26. Answer “yes” when you have completed Table E for all applicable outfalls and attached the results to the application package, or answer “no” if the item is not applicable because you previously submitted WET data to your NPDES permitting authority.

Section 4. Industrial Discharges, Table F, and Hazardous

Wastes

Item 4.1. Indicate if the POTW receives discharges from significant industrial users (SIUs) or categor ical industrial users (CIUs). If “yes,” continue to Item 4.2. If “no,” skip to Item 4.5. SIUs are defined as:

1. All industrial users subject to categorical pretreatment standards under 40 CFR 403.6 and 40 CFR Chapter I, Subchapter N (CIUs); and

2. Any other industrial user per 40 CFR 403.3 that:

a. Discharges an average of 25,000 gpd or more of process wastewater to the treatment works (with certain exclusions); or

b. Contributes a process wastestream that makes up 5 percent or more of the average dry weather hydraulic or organic capacity of the treatment plant; or

c. Is designated as an SIU by the control authority.

Item 4.2. Indicate the number of SIUs and CIUs that discharge to

the POTW.

Item 4.3. Answer whether the POTW has an approved pretreatment program, which is defined at 40 CFR 403.3 as a program administered by a POTW that meets the criteria

established in 40 CFR 403.8 and 403.9 and that has been approved by the NPDES permitting authority.

Item 4.4. Answer whether you have submitted either of the following to the NPDES permitting authority that contains information substantially identical to that required in Table F: (a) a pretreatment program annual report submitted within one year of the application or (b) a pretreatment program. If “yes,” continue to Item 4.5. If “no,” skip to Item 4.6.

Item 4.5. Identify the title and date of the pretreatment program annual report or pretreatment program referenced in Item 4.4 and skip to Item 4.7.

Item 4.6 and Table F. Complete Table F by providing the following information for each SIU and CIU that discharges to the POTW: (a) name and mailing address; (b) description of all industrial processes that affect or contribute to each SIU’s and CIU’s discharge and the SIC or NAICS code(s), if available; (c) a list of the principal products and raw materials that affect or contribute to the SIU’s/CIU’s respective discharges; (d) average daily volume of wastewater discharged by each SIU/CIU, indicating the amount attributable to process flow and n on-process flow; (e) whethe r the SIU or CIU is subject to local limits ; (f) whether the SIU is subject to categorical standards and the categories / subcategories under which the SIU/CIU is subject; and (g) whether any upsets or pass through interferences have occurred at the POTW that can be attributed to the SIU or CIU in the past 4.5 years. Answer “yes” to Item 4.6 when you have completed and attached Table F to the application package.

Note: SIUs and CIUs include users that haul industrial waste to the POTW by truck or rail. Information for these users must be provided

in Table F.

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General Instructions for Reporting, Sampling, and Analysis

IMPORTANT NOTICE: Read these instructions prior to completing Tables A through E and Section 3 of Form 2A.

General Items

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

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

Reporting of Effluent Data

Where effluent data are requested, do not provide information on CSOs. The latter information is requested instead under Section 5

of Form 2A.

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

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

All existing data for pollutants specified in Tables A through D that is collected within 4.5 years of the application must be included in the pollutant data summary that you submit. If, however, you sampled for a specific pollutant on a monthly or more frequent basis, it is only necessary, for such pollutant, to summarize all data collected within 1 year of the application.

Except as specified below, all required quantitative data shall be

collected in accordance with su fficiently sensitive analytical methods approved under 40 CFR part 136 or required under 40 CFR chapter I, subchapter N or O. A method is “sufficiently

sensitive” when:

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

(2) The method ML is above the water quality criterion, but the amount of the pollutant or pollutant parameter in the facility’s discharge is high enough that the method detects and quantifies the level of the pollutant or 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 sensitiveconsistent with 40 CFR 122.21(e)(3)(i). Where no other EPAapproved 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.

Effluent monitoring data must comply with the QA/QC requirements of 40 CFR part 136 (and other appropriate QA/QC requirements for standard methods for analytes not addressed by 40 CFR part 136).

Clearly specify the units of measure on Tables A through E for each parameter / pollutant analyzed. Values should be reported as concentration or mass, with the exception of flow, temperature, pH, color, and fecal coliform organisms, unless otherwise requested or required by the NPDES permitting aut hority. 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)

Grab samples must be used for pH, temperature, cyanide, total phenols, residual chlorine, oil and grease, fecal coliform (including

E. coli ), and volatile organic chemicals. For all other pollutants, 24- hour composite samples must be used. For a composite sample, only one analysis of the composite of aliquots is required.

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General Instructions for Reporting, Sampling, and Analysis Continued

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

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

Note to New Dischargers. Provide all information available to you at the time you complete Form 2A. If you do not have information to respond to a particular item, because your facility has yet to discharge, write or type “data are not available” next to the item on the form. Note that you are required to submit actual data no later than 18 months after your facility commences discharge.

Sampling

The collection of samples for the reported analyses should be supervised by a person experienced in performing sampling of domestic wastewater. You may contact your NPDES permitting authority for detailed guidance on sampling techniques and for answers to specific questions. See Exhibit 2A–1 for contact information. Any specific requirements contained in the 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 shoul d be representative of your normal operation, to the extent feasible, 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 spec ified in your present NPDES permit, or at any site adequate for the collection of a representative sample.

Additional Requirements for Table E, Whole Effluent Toxicity Testing

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

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

Whole effluent toxicity testing must be conducted using methods approved under 40 CFR part 136. West Coast facilities in Washington, Oregon, California, Alaska, Hawaii, and the Pacific Territories are exempted from 40 CFR part 136 chronic methods and must use alternative guidance as directed by the NPDES permitting authority.2A-9 

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FORM 2A

— LINE-BY-LINE INSTRUCTIONS CONTINUED

Section 4. Industrial Discharges, Table F, and Hazardous

Wastes Continued

Item 4.7. Indicate if the POTW receives or has been notified that it will receive by truck, rail, or dedicated pipe any wastes that are regulated as Resource Conservation and Recovery Act (RCRA) hazardous wastes pursuant to 40 CFR Part 261. If “yes,” continue to Item 4.8. If “no,” skip to Item 4.9.

Item 4.8. For each hazardous waste received, provide the hazardous waste number, the method by which the waste is received (e.g., by truck, dedicated pipe, rail, etc.), and the amount of waste received annually (specify units).

Item 4.9. Answer whether the POTW receives, or has been notified that it will receive, wastewaters that originate from remedial activities, including those undertaken pursuant to Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) and sections 3004(u) or 3008(h) of RCRA. If “yes,” continue to Item 4.10. If “no,” skip to Section 5.

Item 4.10. Answer whether the POTW receives (or expects to receive) less than 15 kilograms per month of non-acute hazardous wastes as specified at 40 CFR 261.30(d) and 261.33(e). If “yes,” skip to Section 5. If “no,” continue to Item 4.11.

Item 4.11. In an attachment to the application, provide an identification and description of the site(s) or facility(ies) at which the wastewater originates; the identities of the wastewater’s hazardous constituents, and the extent of treatment, if any, the

wastewater receives or will re ceive before entering the POTW. Answer “yes” to Item 4.11 when you have completed and attached the information to the application package.

Section 5. Combined Sewer Overflows

CSO Map and Diagram

Item 5.1. Indicate if the treatment works has a combined sewer system. If “yes,” continue to Item 5.2. If “no”, skip to Section 6.

Item 5.2. Attach a CSO system map to the application. The map should indicate: (a) all CSO discharge points; (b) sensitive use areas potentially affected by CSOs (beaches, drinking water supplies, shellfish beds, sensitive aquatic ecosystems, and outstanding national resource waters); and (c) waters supporting threatened and endangered species potentially affected by CSOs. Answer “yes” to Item 5.2 when you have completed and attached the map to the application package.

Item 5.3. Prepare a diagram of the CSO collection system. The diagram should show the following: (a) the location of major sewer trunk lines, both combined and separate sanitary; (b) the locations of points where separate sanitary sewers feed into the combined sewer system; (c) in-line and off-line storage structures; (d) the locations of flow-regulating devices; and (e) the locations of pump stations. Answer “yes” to Item 5.3 when you have completed and attached the diagram to the application package.

CSO Outfall Description

Item 5.4. Provide the following information for each CSO outfall: (a) outfall number; (b) city or town, state, ZIP code and county in which the outfall is located; (c) latitude and longitude to the nearest second of the outfall and associated metadata (e.g., horizontal

collection method, scale of source, and horizontal reference datum), (d) distance of outfall from shore; and (e) depth of outfall below water surface. The location of each CSO outfall (i.e., where the coordinates are collected) shall be the point where thedischarge is released into a water of the United States. (See LineBy-Line Instructions to Item 1.1 for guidance on supplying method of collection information.)

CSO Monitoring

Item 5.5. Indicate whether the POTW has monitored any of the following items in the past year for each of its CSO outfalls: (a) rainfall; (b) CSO flow volume; (c) CSO pollutant concentrations; (d) receiving water quality; (e) CSO frequency; and (f) number of

storm events.

CSO Events in Past Year

Item 5.6. For each CSO outfall, record: (a) the number of CSO events in the past year; (b) the average duration in hours per event; (c) the average volume per CSO event in million gallons; and (d) the minimum rainfall that caused a CSO event in inches of rainfall in the past year. Note whether your responses for sub-items (b) through (d) above are based on actual or estimated data.

CSO Receiving Waters

Item 5.7. For each CSO outfall, record the following receiving water information: (a) receiving water name; (b) name of watershed / stream system; (c) U.S. Soil Conservation Service watershed (14- digit) code (if known); (d) name of the state management / river basin; (e) USGS 8-digit hydrological cataloging unit code, if known; and (f) a description of any known water quality impacts on the receiving water caused by the CSO (e.g., permanent or intermittent beach closings, permanent or intermittent shellfish bed closings,
fish kills, fish advisories, other recreational loss, or exceedance of any applicable state water quality standard).

Section 6. Checklist and Certification Statement

Item 6.1. Review the checklist provided. In Column 1, mark the sections of Form 2A that you have completed and are submitting with your application. In Column 2, indicate for each section whether you are submitting attachments.

Item 6.2. The Clean Water Act provides for severe penalties for submitting false information on this application form. CWA Section 309(c)(2) provides that, “Any person who knowingly makes any false statement, representation, or certification in any application, ...shall upon conviction, be punished by a fine of no more than $10,000 or by imprisonment for not more than six months, or both.”

FEDERAL REGULATIONS 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-presi dent of the corporation in charge of a principal business function, or any other person who performs similar policy- or decision-making functions for the corporation, or (ii) the manager of one or more manufacturing, production, or

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operating facilities, provided, the manager is authorized to make management decisions which govern the operation of the regulated facility including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.

B. For partnership or sole proprie torship, by a general partner or the proprietor, respectively. C. For a municipality, State, Federal, or other public facility, By either a principal executive office r or ranking elected official. For purposes of this section, a principal executive officer of a Federal agency includes: (i) The chief executive officer of the agency, or (ii) a senior executiv e officer having responsibility for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrators of EPA).

END

Submit your completed Form a nd all associated attachments to your NPDES permitting authority.2A-11 

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FORM 2A

— GLOSSARY

NOTE: This Glossary includes terms used in the various NPDES applicat ion forms, including Form 2A. The definitions are from the NPDES regulations at 40 CFR 122.2 unless otherwise specified. If you have any questions concerning the meaning of any of these terms, contact your NPDES permitting authority.

ANIMAL FEEDING OPERATION (defined at § 122.23) means a lot or facility (oth er than an aquatic animal production facility) where the following conditions are met;

 Animals ( other than aquatic animals ) have been, are, or will be stabled or confined and fed or maintained for a total of 45 days or more in any 12 month period; and

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

APPLICATION means the EPA standard national forms for applying for a permit, in cluding any additions, revisions, or modifications to the forms; or forms approved by EPA for use in approved stat es, including any approved modifications or revisions.

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

AQUACULTURE PROJECT (defined at § 122.25) means a defined managed water area which uses discharges of pollutants into that designated area for the maintenance or production of harvestabl e freshwater, estuarine, or marine plants or animals. DESIGNATED

PROJECT AREA means the portions of the waters of the United States with in which the permittee or permit applicant plans to confine the cultivated species, using a method or plan or operation (incl uding, but not limited to, physical confinement) which, on the bas is of reliable scientific evidence, is expected to ensure that specific i ndividual organisms comprising an aquaculture crop will enjoy increas ed growth attributable to the discharge of pollutants, and be harvested within a defined geographic area.

AVERAGE MONTHLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar month, calculated as the sum of all daily discharges measured during that month divided by the number of daily discharges measured dur ing that

month.

AVERAGE WEEKLY DISCHARGE LIMITATION means the highest allowable average of daily discharges over a calendar week, calculated as the sum of all daily dischar ges measured during a calendar week divided by the number of daily discharges measured during

that week.

BEST MANAGEMENT PRACTICES (BMP) means schedules of activities, prohibitions of practices, maintenance procedures, and other management practices to prevent or reduce the pollution of waters of the United States. BMPs include treatment requirements, op eration procedures, and practices to control plant site runoff, spillage or leaks, sludge or waste disposal, or drainage from raw mater ial storage.

BIOSOLIDS ( see sewage sludge ).

BYPASS (defined at § 122.41(m)) means the intentional diversion of waste streams from any portion of a treatment facility.

CWA means the Clean Water Act (formerly referred to as the Federal Water Pollution Control Act or Federal Water Pollution Control A ct Amendments of 1972) Public Law 92–500, as amended by Public Law 95–217, Public Law 95–576, Public Law 96–483 and Public Law

97–117, 33 U.S.C. 1251 et seq.

CWA AND REGULATIONS means the Clean Water Act (CWA) and applicable regulations promulgated thereunder. In the case of an approved State program, it includes State program requirements.

COMBINED SEWER OVERFLOW (CSO) means a discharge of untreated wastewater fr om a combined sewer system at a point before the headworks of a publicly owned treatment works. CSOs generally occur during wet weather (rainfall or snowmelt). During perio ds of wet weather, these systems become overloaded, bypass treatment works, and discharge directly to receiving waters at designed overfl ow points.

COMBINED SEWER SYSTEM (CSS) means a wastewater collection system that conv eys sanita ry wastewaters (domestic, commercial and industrial wastewaters) and st ormwater through a single pipe to a publicly owned treatment works for treatment before disch arge to

surface waters.

CONCENTRATED ANIMAL FEEDING OPERATION (defined at § 122.23) means an animal feeding operation which meets the criteria set forth in either (A) or (B) below or which the Di rector designates as such on a case-by-case basis:

A. More than the numbers of animals specified in any of the following categories are confined:

1. 1,000 slaughter or feeder cattle,

2. 700 mature dairy cattle (whether milked or dry cows),

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3. 2,500 swine each weighing over 25 kilograms (approximately 55 pounds),

4. 500 horses,

5. 10,000 sheep or lambs,

6. 55,000 turkeys,

7. 100,000 laying hens or broilers (if the fac ility has a continuous overflow watering),

8. 30,000 laying hens or broilers (if the facility has a liquid manure handling system),

9. 5,000 ducks, or

10. 1,000 animal units; or

B. More than the following numbers and types of animals are confined:

1. 300 slaughter or feeder cattle,

2. 200 mature dairy cattle (whether milked or dry cows),

3. 750 swine each weighing over 25 kilograms (approximately 55 pounds),

4. 150 horses,

5. 3,000 sheep or lambs,

6. 16,500 turkeys,

7. 30,000 laying hens or broilers (if the facility has continuous overflow watering),

8. 9,000 laying hens or broilers (if the facility has a liquid manure handling system),

9. 1,500 ducks, or

10. 300 animal units; AND

Either one of the following conditions are met: Pollutants are di scharged into waters of the United States through a manmade di tch, flushing system or other similar manmade device (“manmade” means constructed by man and used for the purpose of transporting wastes); or Pollutants are discharged directly into waters of the Unites States which originate outside of and pass over, acros s, or through the facility or otherwise come into direct contact with the animals confined in the operation.

Provided, however, that no animal feeding operation is a concent rated animal feeding operation as defined above if such animal feeding operation discharges only in the ev ent of a 25 year, 24 hour storm event.

CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY (defined at § 122.24) means a hatchery, fish farm, or other facility which contains, grows or holds aquatic animals in either of the followi ng categories, or which the Director designates as such on a c ase-by-case

basis:

A. Cold water fish species or other cold water aquatic animals including, but not limited to, the Salmonidae family of fish (e.g., trout and salmon) in ponds, raceways or other similar structures which discharge at least 30 days per year but does not include:

1. Facilities which produce less than 9,090 harvest weight kil ograms (approximately 20,000 pounds) of aquatic animals per year;

and

2. Facilities which feed less than 2,272 kilograms (approximately 5,000 pounds) of food during the calendar month of maximum feeding.

B. Warm water fish species or other warm water aquatic animals including, but not limited to, the Ameiuridae, Cetrarchiclae , and

Cyprinidae families of fish ( e.g., respectively, catfish, sunfish, and minnows ) in ponds, raceways, or other similar structures which discharge at least 30 days per year, but does not include;

1. Closed ponds which discharge only dur ing periods of excess runoff; or

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

DAILY DISCHARGE means the “discharge of a pollutant” measured duri ng a calendar day or any 24- hour period that reasonably represents the calendar day for purposes of sampling. For pollutant s with limitations expressed in units of mass, the “daily di scharge” is

calculated a s the total mass of the pollutant discharged over the day. For pollutants with limitations expressed in other units of measurement, the “daily discharge” is calculated as the average measurement of the pollutant over the day.

DIRECT DISCHARGE means the “discharge of a pollutant.”

DIRECTOR means the Regional Administrator or the State Director, as the context requires, or an author ized representative. When there is no “approved State program,” and there is an EPA administered program, “Director” means the Regional Administrator. When the re is an approved State program, “Director” normally means the State Di rector. In some circumstances, however, EPA retains the author ity to

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— GLOSSARY CONTINUED

take certain actions even when there is an approved State program. (For example, w hen EPA has issued an NPDES permit prior to t he approval of a State program, EPA may retain jurisdiction over t hat permit after program approval, see § 123.1.) In such cases, the term “Director” means the Regional Administrator and not the State Director.

DISCHARGE (OF A POLLUTANT) means:

A. Any addition of any pollutant or combination of pollutants to waters of the United States from any point source; or

B. Any addition of any pollutant or combination of pollutants to t he waters of the contiguous zone or the ocean from any point sou rce other than a vessel or other floating craft which is being used as a means of transportation.

This definition includes discharges into waters of the United St ates from: Surface runoff which is collected or channelled by m an; Discharges through pipes, sewers, or other c onveyances owned by a State, municipality, or other person which do not lead to POT W’s; and discharges through pipes, sewers, or othe r conveyances, leading into privately owned treatment works. This term does not in clude an addition of pollutants by any indirect discharger.

DISCHARGE MONITORING REPORT means the EPA uniform national form, including any subsequent additions, revisions, or modifications for the reporting of self-monitoring results by permittees. DMRs must be used by “approved States” as well as by EPA. EPA will supply DMRs to any approved State upon request. The EPA national forms may be modified to substitute the state agency name

, address, logo, and other similar information, as appropriate, in place of EPA's.

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

EFFLUENT LIMITATION means any restriction imposed by the Director on quantities, discharge rates, and concentrations of “pollutants” which are “discharged” from “point sources” into “waters of the United States,” the waters of the “contiguous zone,” or the oce an.

EFFLUENT LIMITATIONS GUIDELINES means a regulation published by the Administra tor under section 304(b) of CWA to adopt or

revise “effluent limitations.”

ENVIRONMENTAL PROTECTION AGENCY (EPA) means the United States Environmental Protection Agency.

FACILITY or ACTIVITY means any NPDES “point source” or an y other facility or activity (including land or appurtenances thereto) that is subject to regulation under the NPDES program.

GENERAL PERMIT means an NPDES “permit” issued under § 122.28 authorizing a category of discharges under the CWA within a geographical area.

HAZARDOUS SUBSTANCE means any substance designated under 40 CF R part 116 pursuant to section 311 of CWA.

INDIAN COUNTRY means:

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

(2) All dependent Indian communities with the borders of the United St ates whether within the originally or subsequently acquir ed territory
thereof, and whether within or without the limits of a state; and

(3) All Indian allotments, the Indian titles to which have not been extinguished, including rights-of-way running through the s ame.

INDIAN TRIBE means any Indian Tribe, band, group, or community recognized by the Secretary of the Interior and exercising governmental authority over a Federal Indian reservation.

INDIRECT DISCHARGE means a nondomestic discharger introducing “pollut ants” to a “publicly owned treatment works.”

LOG SORTING AND LOG STORAGE FACILITIES (defined at § 122.27) means facilities whos e discharges result from the holding of unprocessed wood, for example, logs or roundwood with bark or after removal of bark held in self-contained bodies of water (mil l ponds or log ponds) or stored on land where water is applie d intentionally o n the logs (wet decking). (See 40 CFR part 429, subpart I, i ncluding the effluent limitations guidelines.)

MAJOR FACILITY means any NPDES “facility or activity” classified as such by the Regional Administrator, or, in the case of “approved State programs,” the Regional Administrator in conjunction with the State Director.

MAXIMUM DAILY DISCHARGE LIMITATION means the highest allowable “daily discharge.”

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MUNICIPALITY means a city, town, borough, county, parish, district, associ ation, or other public body created by or under State law and having jurisdiction over disposal of sewage, industrial wastes , or other wastes, or an Indian tribe or an authorized Indian tri bal organization, or a designated and approved management agency under section 208 of CWA.

MUNICIPAL SEPARATE STORM SEWER SYSTEM (MS4) (defined at § 122.26 (b)(4) and (b)(7)) means a conveyance or system of conveyances (including roads with drainage systems, municipal st reets, catch basins, curbs, gutters, ditches, man-made channels , or storm drains):

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

 Designed or used for collecting or conveying stormwater.

 [That] is not a combined sewer.

 [That] is not part of a Publicly Owned Treatm ent Works (POTW) as defined at § 122.2.

MUNICIPAL SLUDGE (see sewage sludge)

NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) means the national program for issuing, modifying, revoking and reissuing, terminating, monitoring and enforcing permits, and imposing and enforcing pretreatment requirements, under secti ons 307, 402, 318, and 405 of CWA. The term includes an “approved program.”

NEW DISCHARGER means any building, structure, facility, or installation:

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

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

(c) Which is not a “new source;” and

(d) Which has never received a finally effectiv e NDPES permit for discharges at that “site.”

This definition includes an “indirect discharger” which commences discharging into “waters of the United States” after August 1 3, 1979. It also means any existing mobile point source (other than an offs hore or coastal oil and gas exploratory drilling rig or a coasta l oil and gas developmental drilling rig) such as a seafood processing rig, s eafood processing vessel, or aggregate plant, that begins discha rging at a “site” for which it does not have a permit; and any offshore or c oastal mobile oil and gas exploratory drilling rig or coastal mobile oil and gas developmental drilling rig that commences the discharge of pollu tants after August 13, 1979, at a “site” under EPA's permitting jurisdiction for which it is not covered by an individual or general permi t and which is located in an area determined by the Regional Admin istrator in the issuance of a final permit to be an area of biological concer n. In determining whether an area is an area of biological con cern, the Regional Administrator shall consider the factor s specified in 40 CFR 125.122(a) (1) through (10).

An offshore or coastal mobile explorator y drilling rig or coastal mobile developmen tal drilling rig will be considered a “new d ischarger” only for the duration of its discharge in an area of biological concern.

NEW SOURCE means any building, structure, facility, or installation from which there is or may be a “discharge of pollutants,” the

construction of which commenced:

(a) After promulgation of standards of performance under se ction 306 of CWA which are applicable to such source, or

(b) After proposal of standards of performance in accordance with section 306 of CWA which are applicable to such source, but o nly if the standards are promulgated in accordance with section 306 within 120 days of their proposal.

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

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

PESTICIDE APPLICATIONS TO WA TERS OF THE UNITED STATES means the application of biological pesticides, and the application of chemical pesticides that leave a residue, from point sources to waters of the United States. In the context of this definiti on of pesticide applications to waters of the United States, this does not in clude agricultural stormwater disc harges and return flows from irr igated agriculture, which are excluded by law (Id. § 1342(l)).

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— GLOSSARY CONTINUED

POINT SOURCE means any discernible, confined, and discrete conveyance, in cluding but not limited to, any pipe, ditch, channel, tunnel, conduit, well, discrete fissure, container, rolling stock, concentrated animal feeding operation, landfill leachate collection system, vessel or other floating craft from which pollutants are or may be dischar ged. This term does not include return flows from irrigated agr iculture or agricultural stormwater runoff. (See § 122.3).

POLLUTANT means dredged spoil, solid waste, incinerator residue, f ilter backwash, sewage, garbage, sewage sludge, munitions, chemical wastes, biological materials, radioactive materials (e xcept those regulated under the Atomic Energy Act of 1954, as am ended (42

U.S.C. 2011 et seq. )), heat, wrecked or discarded equipment, rock, sand, cellar dirt and industrial, municipal, and agricultural waste discharged into water. It does not mean:

(a) Sewage from vessels; or

(b) Water, gas, or other material which is injected into a we ll to facilitate production of oil or gas, or water derived in ass ociation with oil and gas production and disposed of in a well, if the well used either to facilitate production or for disposal purposes is approved by authority of
the State in which the well is located, and if the State determines that the injection or disposal will not result in the degra dation of ground or surface water resources. Note: Radioactive materials covered by the Atomic Energy Act are those encompassed in its definition o f source, byproduct, or special nuclear materials. Examples of material s not covered include radium and accelerator-produced isotopes. Se e Train v. Colorado Public Interest Research Group, Inc., 426 U.S. 1 (1976).

PRIMARY INDUSTRY CATEGORY means any industry category listed in the NRDC settlement agreement ( Natural Resources Defense

Council et al. v. Train, 8 E.R.C. 2120 (D.D.C. 1976), modified 12 E.R.C. 1833 (D.D.C. 1979)); also listed in appendix A of part 122.

PRIVATELY OWNED TREATMENT WORKS means any device or system which is (a) used to treat wastes from any facility whose operator is not the operator of the treatment works and (b) not a “POTW.”

PROCESS WASTEWATER means any water which, during manufacturing or processing, comes into direct contact with or results from the production or use of any raw material, intermediat e product, finished product, byproduct, or waste product.

PROPOSED PERMIT means a State NPDES “permit” prepared after the clos e of the public comment period (and, when applicable, any public hearing and administrative appeals) which is sent to EPA for review before final issuance by the State, or a State NPDES permit designated as a proposed permit under § 123.44(k). A “proposed permit” is not a “draft permit.”

PUBLICLY OWNED TREATMENT WORKS or POTW (defined at § 403.3) means a treatment works as defined by CWA Section 212, which is owned by a state or municipality [as defined by CWA Se ction 502(4)]. This definition includes any devices or systems u sed in the storage, treatment, recycling, and reclamation) of municipal sewage or industrial wastes of a liquid nature. This definition al so includes sewers, pipes, and other conveyances only if they convey wastewat er to a POTW. The term also means the municipality as defined in CWA Section 502(4), which has jurisdiction over the indirect di scharges to and the discharges from such a treatment works.

REGIONAL ADMINISTRATOR means the Regional Administrator of the appropriate Regional Office of the Environmental Protection Agency or the authorized representativ e of the Regional Administrator.

ROCK CRUSHING AND GRAVEL WASHING FACILITIES (defined at § 122.27) means facilities which process crushed and broken stone, gravel, and riprap (See 40 CFR part 436, subpart B, including the effluent limitations guidelines).

SCHEDULE OF COMPLIANCE means a schedule of remedial measures included in a “permit”, including an enforceable sequence of interim requirements (for example, actions, operations, or milestone events) leading to compliance with the CWA and regulations

.

SECOND ARY I NDUSTRY CATEGORY means any industry category which is not a primary industry category.

SEWAGE FROM VESSELS means human body wastes and the wastes from toilets and other receptacles intended to receive or retain body wastes that are discharged from vessels and regulated under section 312 of CWA, except that with respect to commercial ves sels on the Great Lakes this term includes graywater. For the purposes of this definition, “graywater” means galley, bath, and shower w ater.

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

SlLVICULTURAL POINT SOURCE (defined at § 122.27) means any discernible, confined, and discrete conveyance related to rock crushing, gravel washing, log sorting, or log storage facilit ies which are operated in connection with silvicultural activities and from which pollutants are discharged into waters of the United States. This term does not include nonpoint source silvicultural activities such as nursery operations, site preparation, reforestation and subsequent cultural treatment, thinning, prescribed burning, pest and f ire control, harvesting operations, surface drainage, or road construction and maintenance from whic h there is natural runoff. However, some of these activities (such as stream crossing for roads) may involve po int source discharges of dredged or fill material which may requir e a CWA Section 404 permit (see 33 CFR 209.120 and part 233).

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— GLOSSARY CONTINUED

SITE means the land or water area where any “facility or activity” is physically located or conducted, including adjacent land used in connection with the facility or activity.

SLUDGE ONLY FACILITY means any “treatment works treating domestic sewage” whose methods of sewage sludge use or disposal are subject to regulations promulgated pursuant to section 405(d) of the CWA and is required to obtain a permit under § 122.1(b)(2)

.

STANDARDS FOR SEWAGE SL UDGE USE OR DISPOSAL means the regulations promulgated purs uant to section 405(d) of the CWA which govern minimum requirements for sludge quality, management practices, and monitoring and reporting applicable to sewage s ludge or the use or disposal of sewage sludge by any person.

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

STATE DIRECTOR means the chief administrative officer of any State or interstate agency operating an “ approved program,” or the delegated representative of the State Director. If responsibility is divided among two or more State or interstate agencies, “S tate Director”

means the chief administrative officer of the State or inters tate agency authorized to perform t he particular procedure or func tion to which

reference is made.

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

STORMWATER DISCHARGE ASSOCIATED WITH INDUSTRIAL ACTIVITY (defined at § 122.26(b)(14)) means the discharge from any conveyance that is used for collecting and c onveying stormwater and that is directly related to manufacturing, processing or raw materials storage areas at an industrial plant. The term does not include di scharges from facilities or activities excluded from the NPDE S program under this part 122. For the categories of industries identified in this section, the term includes, but is not limited to, sto rmwater discharges from industrial plant yards; immediate access roads and rail lines used or traveled by carriers of raw materials, manufactured products, waste material, or by-products used or cr eated by the facility; material handling sites; refuse sites; sites used for the appli cation or disposal of process waste waters (as defined at part 401 of this chapt er); sites used for the storage and maintenance of material handli ng equipment; sites used for residual treatment, storage, or dispos al; shipping and receiving areas; manufacturing buildings; stor age areas (including tank farms) for raw materials, and intermediate and fi nal products; and areas where industrial activity has taken pl ace in the past and significant materials remain and are exposed to stormwater. For the purposes of this paragraph, material handling activitie s include storage, loading and unloading, transportation, or conveyance of an y raw material, intermediate product, final product, by-product or waste product. The term excludes areas located on plant lands separate from the plant's industrial activities, such as office buildin gs and accompanying parking lots as long as the drainage from the excl uded areas is not mixed with stormwater drained from the above described areas. Industrial facilities (including industrial faci lities that are federally, Stat e, or municipally owned or oper ated that meet the description of the facilities listed in paragraphs (b)(14)(i) thr ough (xi) of this section) include those facilities designated under the provisions of paragraph (a)(1)(v) of this section. The following categor ies of facilities are considered to be engaging in “industrial act ivity” for purposes of paragraph (b)(14):

(i) Facilities subject to stormwater effluent limitations guidelines, new source performance standards, or toxic pollutant effl uent standards under 40 CFR subchapter N (except facilities with toxic pollut ant effluent standards which are exempted under category (xi) in paragraph (b)(14) of this section);

(ii) Facilities classified as Standard Industr ial Classifications 24, Industry Group 241 that are rock crushing, gravel washing, log sorting, or log storage facilities operated in connection with silvicultural activities defined in 40 CFR 122.27(b)(2)-(3) and Industry Gro ups 242 through 249; 26 (except 265 and 267), 28 (except 283), 29, 311, 32 (except 323), 33, 3441, 373; (not included are all other types of si lvicultural facilities);

(iii) Facilities classified as Standard Industrial Classification s 10 through 14 (mineral industry) including active or inactiv e mining operations (except for areas of coal mining operations no longer meeting the definition of a reclamation area under 40 CFR 434.11(1) becau se the performance bond issued to the facility by the appropriate SMCRA authority has been released, or except for areas of non-coal m ining operations which have been released from applic able State or Federal reclamation requirements after December 17, 1990) and oil and gas exploration, production, processing, or tr eatment operations, or transmission faciliti es that discharge stormwater contaminated by contact with or that has come into contact with, any overburden, ra w material, intermediate products, finished products, byproducts or waste products located on the site of such operations; (inactive mini ng operations are mining sites that are not being actively mined , but which have an identifiable owner/operator; inactive mining sites do not include sites where mining claims are being maintained prior to disturbances associated with the extraction, beneficiation, or pr ocessing of mined materials, nor sites where minimal activities are undertaken for the sole purpose of maintaining a mining claim);

(iv) Hazardous waste treatment, storage, or disposal facilities, including those that are operating under interim status or a p ermit under
subtitle C of RCRA;

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(v) Landfills, land application sites, and open dumps that receive or have received any industrial wastes (waste that is receiv ed from any of the facilities described under this subsection) including those that are subject to regulation under subtitle D of RCRA;

(vi) Facilities involved in the recycling of materials, including metal scrapyards, battery reclaimers, salvage yards, and auto mobile junkyards, including but limited to those classified as Standard Industrial Classification 5015 and 5093;

(vii) Steam electric power generating fa cilities, including coal handling sites;

(viii) Transportation facilities classified as Standard Industrial Classifications 40, 41, 42 (except 4221–25), 43, 44, 45, and 5171 which have vehicle maintenance shops, equipment cleaning operations, or air port deicing operations. Only those portions of the facility th at are either involved in vehicle maintenance (including vehicle rehabilitation, mechanical repairs, painting, fueling, and lubrication), equ ipment cleaning operations, airport deicing operations, or wh ich are otherwise identified under paragraphs (b)(14) (i)–(vii) or (ix)–(xi) of th is section are associated with industrial activity;

(ix) Treatment works treating domestic sew age or any other sewage sludge or wastewater treatment device or system, used in the storage treatment, recycling, and reclamation of municipal or domestic sewage, including land dedicated to the disposal of sewage sludg e that are located within the confines of the facility, with a design flow of 1.0 mgd or more, or required to have an approved pretreatmen t program under 40 CFR part 403. Not included are farm lands, domestic gardens or lands used for sludge management where sludge is benefi cially reused and which are not physically located in the confines of th e facility, or areas that are in compliance with section 405 o f the CWA;

(x) Construction activity including clearing, grading and excavati on, except operations that result in the disturbance of less than five acres of total land area. Construction activity also includes the disturbance of less than five acres of total land area that is a pa rt of a larger common plan of development or sale if the larger comm on plan will ultimately disturb five acres or more;

(xi) Facilities under Standard Industrial Classifications 20, 21, 22, 23, 2434, 25, 265, 267, 27, 283, 285, 30, 31 (except 311), 323, 34 (except 3441), 35, 36, 37 (except 373), 38, 39, and 4221–25;.

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

TREATMENT WORKS TREATING DOMESTIC SEWAGE (TWTDS) means a POTW or any other sewage sludge or waste water treatment devices or systems, regardless of ownership (including federal facilities), used in the storage, treatment, recycling , and reclamation of municipal or domestic sewage, including land dedicated for the disposal of sewage sludge. This definition does n ot include septic tanks or similar devices. For purposes of this definition, “domestic sewage” includes waste and waste water from humans or household operations that are discharged to or otherwise enter a tr eatment works. In States where there is no approved State sl udge management program under section 405(f) of the CWA, the Regional Administrator may designate any person subject to the standard s for sewage sludge use and disposal in 40 CFR part 503 as a “treatment works treating domestic sewage,” where he or she finds that t here is a potential for adverse effects on public health and the environm ent from poor sludge quality or poor sludge handling, use or d isposal practices, or where he or she finds that such designation is necessary to ensure that such person is in compliance with 40 CFR part 503.

UPSET (defined at § 122.41(n)) means an exceptional incident in wh ich there is unintentional and temporary noncompliance with technology based permit effluent limitations because of factor s beyond the reasonable control of the permittee. An upset does n ot include noncompliance to the extent caused by operational error, im properly designed treatment facilities, inadequate treatment facilit ies, lack of preventive maintenance, or ca reless or improper operation.

VARIANCE means any mechanism or provision under section 301 or 316 of CWA or under 40 CFR part 125, or in the applicable “effluent limitations guidelines” which allows modification to or waiver of th e generally applicable effluent limitation requirements or time deadlines of

CWA. This inclu des provisions which allow the establishment of alternative limitations based on fundamentally different factors or on sections 301(c), 301(g), 301(h), 301(i), or 316(a) of CWA.

WATERS OF THE UNITED STATES (defined at § 122.2) means:

(a) All waters which are currently used, were used in the past, or may be susceptible to use in interstate or foreign commerce, including all waters which are subject to the ebb and flow of the tide;
(b) All interstate waters, including interstate “wetlands;”

(c) All other waters such as intrastate lakes, rivers, stream s (including intermittent streams), mudflats, sandflats, “wetlands,” sloughs, prairie potholes, wet meadows, playa lakes, or natural ponds, the use, degradation, or destruction of which would affect or cou ld affect interstate or foreign commerce including any such waters:
(1) Which are or could be used by interstate or fo reign travelers for recreational or other purposes;

(2) From which fish or shellfish are or could be ta ken and sold in interstate or foreign commerce; or

(3) Which are used or could be used for industrial pur poses by industries in interstate commerce;

(d) All impoundments of waters otherwise defined as waters of the United States under this definition;

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(e) Tributaries of waters identified in paragraphs (a) through (d) of this definition;

(f) The territorial sea; and

(g) “Wetlands” adjacent to waters (other than waters that are themselves wetlands) identified in paragraphs (a) through (f) of this definition.

Waste treatment systems, including treatment ponds or lagoons designed to meet the requirements of CWA (other than cooling pond s as defined in 40 CFR 423.11(m) which also meet the criteria of this definition) are not waters of the United States. This exclusio n applies only to manmade bodies of water which neither were originally created in waters of the United States (such as disposal area in wetla nds) nor resulted from the impoundment of waters of the United States. [See Note 1 of this section.] Waters of the United States do not include prior converted cropland. Notwithstanding the determination of an area's status as prior converted cropland by any other federal agen cy, for the purposes of the Clean Water Act, the final authority regar ding Clean Water Act jurisdiction remains with EPA.

WHOLE EFFLUENT TOXICITY (WET) means the aggregate toxic effect of an effluent measured directly by a toxicity test where the test results are based on acute (lethal) and/or chronic (lethal and sublethal) endpoints.EPA Form 3510-2A (Revised <INSERT DATE>) Page 1 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



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Draft Application Forms

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2A

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

NEW AND EXISTING PUBLICLY OWNED TREATMENT WORKS

SECTION 1. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS (40 CF R 122.21(j)(1) and (9))Facility Information 1.1 Facility Name

Mailing Address (Street or P.O. Box)

City or Town State ZIP Code

Contact Name (first and last) Title Phone Number Email Address

Location Address (Street, Route Number or Other Specific Identifier) 

##  Same as mailing address

City or Town State ZIP Code

Facility Latitude/Longitude (See Instructions.)

Latitude Longitude Degrees Minutes Seconds Degrees Minutes Seconds

Reference Point (Check one.) Collection Method Information 

##  Entrance to Facility



##  Center of Facility



##  Other (specify) 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)

1.2 Is this application for a facility that has yet to commence discharge?



##  Yes  See Instructions regarding data submission requirements for new dischargers. 

##  NoApplicant Information 1.3 Is applicant different from entity listed under Item 1.1 above?



##  Yes 

##  No  SKIP to Item 1.4.

Applicant Name

Applicant Address (Street or P.O. Box)

City or Town State ZIP Code

Contact Name (first and last) Title Phone Number Email Address

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



##  Owner 

##  Operator 

##  Both

1.5 To which entity should the NPDES permitting authority send correspondence? (Check only one response.)



##  Facility 

##  Applicant 

##  Facility and Applicant (They are one in the same.)EPA Form 3510-2A (Revised <INSERT DATE>) Page 2 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



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Draft Application Forms

– Not for ImplementationExisting Environmental Permits 1.6 Indicate below any existing environmental permits. (Che ck all that apply and print or type the corresponding permit number for each.)

Existing Environmental Permits 

##  NPDES (discharges to surface water) 

##  RCRA (hazardous waste) 

##  UIC (underground injection control)



##  PSD (air emissions) 

##  Nonattainment program (CAA) 

##  NESHAPS (CAA)



##  Ocean dumping (MPRSA) 

##  Dredge or fill (CWA section 404) 

##  Other (specify)Collection System and Population Served 1.7 Provide the collection system informati on requested below for the treatment works. Municipality

Served Population

Served Collection System Type (indicate percentage) Ownership Status

_____ % Separate sanitary sewer  Own  Maintain

_____ % Combined storm and sanitary

sewer  Own  Maintain

 Unknown  Own  Maintain _____ % Separate sanitary sewer  Own  Maintain

_____ % Combined storm and sanitary

sewer  Own  Maintain

 Unknown  Own  Maintain _____ % Separate sanitary sewer  Own  Maintain

_____ % Combined storm and sanitary

sewer  Own  Maintain

 Unknown  Own  Maintain _____ % Separate sanitary sewer  Own  Maintain

_____ % Combined storm and sanitary

sewer  Own  Maintain

 Unknown  Own  Maintain

Total Population

Served

Total Percentage of Each Type of

Sewer Line (in miles) Separate Sanitary Sewer System Combined Storm and Sanitary Sewer

% %Indian Country 1.8 Is the treatment works located in Indian Country?


##  Yes 

##  No

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


##  Yes 

##  NoDesign and ActualFlow Rates 1.10 Provide design and actual flow rates in the designated spaces. Design Flow Rate

mgd

Annual Average Flow Rates (Actual)

Two Years Ago Last Year This Year

mgd mgd mgd

Maximum Daily Flow Rates (Actual)

Two Years Ago Last Year This Year

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

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



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– Not for ImplementationDischarge Pointsby Type 1.11 Provide the total number of effluent discharge po ints to waters of the United States by type.
Total Number of Effluent Discharge Points by Type

Treated Effluent Untreated Effluent Combined Sewer

Overflows Bypasses Constructed Emergency

OverflowsOutfalls and Other Discharge or Disposal Methods Outfalls Other Than to Waters of the United States
1.12 Does the POTW discharge wastewater to basins, ponds, or other surface impoundments that do not have outlets for discharge to waters of the United States? 

##  Yes 

##  No  SKIP to Item 1.14.

1.13 Provide the location of each surface impoundment and associated discharge information in the table below. Surface Impoundment Location and Discharge Data

Location Average Daily Volume Discharged to Surface Impoundment Continuous or Intermittent (Check one.)

gpd  Continuous

 Intermittent

gpd  Continuous

 Intermittent

gpd  Continuous

 Intermittent

1.14 Is wastewater applied to land? 

##  Yes 

##  No  SKIP to Item 1.16.

1.15 Provide the land application site and discharge data requested below. Land Application Site and Discharge Data

Location Size Average Daily Volume Applied Continuous or

Intermittent (Check one.)

acres gpd  Continuous

 Intermittent

acres gpd  Continuous

 Intermittent

acres gpd  Continuous

 Intermittent 1.16 Is effluent transported to another facility for treatment prior to discharge? 

##  Yes 

##  No  SKIP to Item 1.21.

1.17 Describe the means by which the effluent is transported (e.g., tank truck, pipe).

1.18 Is the effluent transported by a party other than the applicant? 

##  Yes 

##  No  SKIP to Item 1.20.

1.19 Provide information on the transporter below. Transporter Data Entity Name Mailing Address (Street or P.O. Box)

City or Town State ZIP Code

Contact Name (first and last) Title

Phone Number Email AddressEPA Form 3510-2A (Revised <INSERT DATE>) Page 4 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



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Draft Application Forms

– Not for ImplementationOutfalls and Other Discharge or Disposal Methods Continued 1.20 In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the receiving facility. Receiving Facility Data Facility Name Mailing Address (Street or P.O. Box)

City or Town State ZIP Code

Contact Name (first and last) Title

Phone Number Email Address

NPDES Number of Receiving Facility (if any)  None Average Daily Flow Rate mgd 1.21 Is the wastewater disposed to places/structures (other than those already mentioned) that do not have outlets to waters of the United States (e.g., underground percolation, underground injection)?



##  Yes 

##  No  SKIP to Item 1.23.

1.22 Provide information in the table below on these other disposal methods. Information on Other Disposal Methods Disposal

Method Description Location of Disposal Site Size of Disposal Site Annual Average Daily Discharge

Volume Continuous or Intermittent (Check one.)

acres gpd  Continuous

 Intermittent

acres gpd  Continuous

 Intermittent

acres gpd  Continuous

 IntermittentContractor Information 1.23 Are any operational or maintenance aspects (related to wast ewater treatment and effluent quality) of the treatment works the responsibility of a contractor? 

##  Yes 

##  No  SKIP to Section 2.

1.24 Provide location and contact information for each contract or in addition to a description of the contractor's O&M responsibilities.

Contractor Information

Contractor 1 Contractor 2 Contractor 3

Contractor Name (company name) Mailing Address (Street or P.O. Box) City, State, and ZIP

Code Contact Name (first and last)

Phone Number

Email Address

O&M Responsibilities of

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

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



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Draft Application Forms

– Not for Implementation SECTION 2. ADDITIONAL INFORMATION (40 CFR 122.21(j)(1) and (2))Design Flow Outfalls to Waters of the United States

2.1 Does the treatment works have a design flow greater than or equal to 0.1 mgd?



##  Yes 

##  No  SKIP to Section 3.Inflow and Infiltration 2.2 Provide the treatment work’s current average daily volume of inflow

and infiltration. Average Daily Volume of Inflow and Infiltration

gpd

Indicate the steps the facility is taking to minimize inflow and infiltration.TopographicMap 2.3 Have you attached a topographic map containing all required information to this application? (See Instructions for specific requirements.)



##  Yes 

##  NoFlowDiagram 2.4 Have you attached a process flow diagram or schematic containing all required information to this application? (See Instructions for specific requirements.)



##  Yes 

##  NoScheduled Improvements and Schedules of Implementation 2.5 Are improvements to the facility scheduled?



##  Yes 

##  No  SKIP to Section 3.

Briefly list and describe t he scheduled improvements.

1.

2.

3.

4.

2.6 Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements

Scheduled Improvement (from above) Affected

Outfalls (list Outfall Number) Begin

Construction (MM/DD/YYYY) End

Construction (MM/DD/YYYY) Begin Discharge (MM/DD/YYYY) Attainment of Operational

Level (MM/DD/YYYY)

1.

2.

3.

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

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



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– Not for Implementation 2.7 Have appropriate permits/clearances conc erning other federal/state requirem ents been obtained? Briefly explain your

response. 

##  Yes 

##  No 

##  None required or applicable

Explanation:

SECTION 3. INFORMATION ON EFFLUENT DI SCHARGES (40 CFR 122.21(j)(3) to (5))Description of Outfalls 3.1 Provide the following information for each outfall. (Attach additional sheets if you have more than three outfalls.)

Outfall Number ______ Outfall Number _____ Outfall Number ______

State

County

City or Town

Distance from Shore ft. ft. ft.

Depth Below Surface ft. ft. ft.

Average Daily Flow Rate mgd mgd mgd

Latitude

Longitude

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  Not Applicable  Not Applicable

Horizontal Reference

Datum (Coordinate reference system)  NAD 27  NAD 83

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

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

 WGS85  Other (specify)Seasonal or Periodic Discharge Data 3.2 Do any of the outfalls described under Ite m 3.1 have seasonal or periodic discharges?



##  Yes 

##  No  SKIP to Item 3.4.

3.3 If so, provide the following information for each applicable outfall.

Outfall Number _____ Outfall Number _____ Outfall Number _____

Number of times per year discharge occurs Average duration of each discharge (specify units)
Average flow of each discharge mgd mgd mgd

Months in which discharge

occursDiffuser Type 3.4 Are any of the outfalls listed under Item 3.1 equipped with a diffuser?



##  Yes 

##  No  SKIP to Item 3.6.

3.5 Briefly describe the diffuser type at each applicable outfall.

Outfall Number _____ Outfall Number _____ Outfall Number _____EPA Form 3510-2A (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 ImplementationWaters ofthe U.S. 3.6 Does the treatment works discharge or plan to discharge wastew ater to waters of the United States from one or more discharge points?

 Yes  No  SKIP to Section 6.Receiving Water Description 3.7 Provide the receiving water and related information (if known) for each outfall.

Outfall Number _____ Outfall Number _____ Outfall Number _____

Receiving Water Name

Watershed, River or Stream System

14-Digit Watershed Code

State Management / River

Basin

8-Digit Hydrological Cataloging Unit Code

Critical Low Flow (Acute) cfs cfs cfs

Critical Low Flow (Chronic) cfs cfs cfs

Total Hardness at Critical

Low Flow mg/L of

CaCO 3 mg/L of

CaCO 3 mg/L of

CaCO 3Treatment Description 3.8 Provide the following information describing the treatment provided for discharges from each outfall.

Outfall Number _____ Outfall Number _____ Outfall Number _____

Highest Level of

Treatment (Check all that apply per outfall.)  Primary

 Equivalent to Secondary

 Secondary

 Advanced

 Other (specify)  Primary

 Equivalent to Secondary

 Secondary

 Advanced

 Other (specify)  Primary

 Equivalent to Secondary

 Secondary

 Advanced

 Other (specify)

Design Removal Rates by

Outfall

BOD 5 or CBOD 5 % % %

TSS % % %

Phosphorus  Not applicable  Not applicable  Not applicable

% % %

Nitrogen  Not applicable  Not applicable  Not applicable

% % %

Other (specify)  Not applicable  Not applicable  Not applicable

% % %EPA Form 3510-2A (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 ImplementationTreatment Description Continued 3.9 Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.

Outfall Number _____ Outfall Number _____ Outfall Number _____

Disinfection Type

Seasons Used

Dechlorination Used? 

## 

 Not Applicable 

##  Not Applicable 

##  Not Applicable

Yes 

##  Yes 

##  Yes


##  No 

##  No 

##  NoEffluent Testing Data 3.10 Have you completed monitoring for all Table A parameters and attached the results to the application package? 

##  Yes 

##  No

3.11 Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility’s discharges or on any receiving water near the discharge points? 

##  Yes 

##  No  SKIP to Item 3.13.

3.12 Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility’s discharges by outfall number or of the receiving water near the discharge points.

Outfall Number _____ Outfall Number ______ Outfall Number _____

Acute Chronic Acute Chronic Acute Chronic

Number of tests of discharge

water Number of tests of receiving

water 3.13 Does the treatment works have a design flow greater than or equal to 0.1 mgd? 

##  Yes 

##  No  SKIP to Item 3.16.

3.14 Does the POTW use chlorine for disinfection, use chlori ne elsewhere in the treatment process, or otherwise have reasonable potential to discharge chlorine in its effluent? 

##  Yes  Complete Table B, including chlorine. 

##  No  Complete Table B, omitting chlorine.

3.15 Have you completed monitoring for all applicable Table B pollutants and attached the results to this application package? 

##  Yes 

##  No

3.16 Do one or more of the following conditions apply?

1. The facility has a design flow greater than or equal to 1 mgd.

2. The POTW has an approved pretreatment program or is required to develop such a program.

3. The NPDES permitting authority has informed the POTW that it must sample for the parameters in Table C, must sample other additional parameters (Table D), or submit the results of WET tests for acute or chronic toxicity for each of its discharge outfalls (Table E).



##  Yes  Complete Tables C, D, and E as applicable. 

##  No  SKIP to Section 4.

3.17 Have you completed monitoring for all applicable Table C pollutants and attached the results to this application package? 

##  Yes 

##  No

3.18 Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and attached the results to this application package?



##  Yes 

##  No additional sampling required by NPDES permitting authority.EPA Form 3510-2A (Revised <INSERT DATE>) Page 9 EPA Identification Number NPDES Permit Number Facility Name Form Approved

OMB No. <INSERT NO.> Form Expires <INSERT DATE>



### Contains Nonbinding Recommendations

Draft Application Forms

– Not for ImplementationEffluent Testing Data Continued 3.19 Has the POTW conducted either (a) minimum of four quarterly WET tests for one year preceding this permit application or (b) at least four annual WET tests in the past 4.5 years?



##  Yes 

##  No  Complete tests and Table E and SKIP to

Item 3.26. 3.20 Have you previously submitted the results of the above tests to your NPDES permitting authority?



##  Yes 

##  No  Provide results in Table E and SKIP to

Item 3.26. 3.21 Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results. Date(s) Submitted

(MM/DD/YYYY) Summary of Results

3.22 Regardless of how you provided your WET testing data to t he NPDES permitting authority, did any of the tests result in toxicity? 

##  Yes 

##  No  SKIP to Item 3.26.
3.23 Describe the cause(s) of the toxicity:

3.24 Has the treatment works conducted a Toxicity Reduction Evaluation? 

##  Yes 

##  No  SKIP to Item 3.26.

3.25 Provide details of any Toxicity Reduction Evaluations conducted.

3.26 Have you completed Table E for all applicable outfalls and attached the results to the application package?



##  Yes 

##  Not applicable because previously submitted information to the NPDES permitting authority.

SECTION 4. INDUSTRIAL DISCHARGES AND HAZ ARDOUS WASTES (40 CFR 122.21(j)(6) and (7))Industrial Discharges and Hazardous Wastes 4.1 Does the POTW receive discharges from SIUs or CIUs? 

##  Yes 

##  No  SKIP to Item 4.7.

4.2 Indicate the number of SIUs and CIUs that discharge to the POTW.

Number of SIUs Number of CIUs

4.3 Does the POTW have an approved pretreatment program?



##  Yes 

##  No

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



##  Yes 

##  No  SKIP to Item 4.6.

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

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



##  Yes 

##  NoEPA Form 3510-2A (Revised <INSERT DATE>) Page 10 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 4.7 Does the POTW receive, or has it been notified that it will re ceive, by truck, rail, or dedicated pipe, any wastes that are regulated as RCRA hazardous wastes pursuant to 40 CFR Part 261?



##  Yes 

##  No  SKIP to Item 4.9.Industrial Discharges and Hazardous Wastes Continued 4.8 If yes, provide the following information:

Hazardous Waste

Number Waste Transport Method (Check all that apply.) Annual

Amount of

Waste

Received Units



##  Truck 

##  Rail



##  Dedicated Pipe 

##  Other (specify)



##  Truck 

##  Rail



##  Dedicated Pipe 

##  Other (specify)



##  Truck 

##  Rail



##  Dedicated Pipe 

##  Other (specify)

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



##  Yes 

##  No  SKIP to Section 5.

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



##  Yes  SKIP to Section 5. 

##  No

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



##  Yes 

##  No

SECTION 5. COMBINED SEWER O VERFLOWS (40 CFR 122.21(j)(8))CSO Map and Diagram 5.1 Does the treatment works have a combined sewer system?



##  Yes 

##  No  SKIP to Section 6.

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



##  Yes 

##  No

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



##  Yes 

##  NoEPA Form 3510-2A (Revised <INSERT DATE>) Page 11 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 ImplementationCSO Outfall Description 5.4 For each CSO outfall, provide the following info rmation. (Attach additional sheets as necessary.)

CSO Outfall Number ____ CSO Outfall Number _____ CSO Outfall Number _____

City or Town

State and ZIP Code

County

Latitude

Longitude

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  Not Applicable  Not Applicable

Horizontal Reference

Datum (Coordinate reference system)  NAD 27  NAD 83

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

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

 WGS85  Other (specify)

Distance from Shore ft. ft. ft.

Depth Below Surface ft. ft. ft.CSO Monitoring 5.5 Did the POTW monitor any of the following items in the past year for its CSO outfalls?

CSO Outfall Number ____ CSO Outfall Number _____ CSO Outfall Number _____

Rainfall 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No

CSO Flow Volume 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No

CSO Pollutant

Concentrations 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No

Receiving Water Quality 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No

CSO Frequency 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  No

Number of Storm Events 

###  Yes 

###  No 

###  Yes 

###  No 

###  Yes 

###  NoCSO Events in Past Year 5.6 Provide the following information for each of your CSO outfalls.

CSO Outfall Number ____ CSO Outfall Number ____ CSO Outfall Number ____

Number of CSO Events in

the Past Year events events events

Average Duration Per

Event hours hours hours

 Actual or  Estimated  Actual or  Estimated  Actual or  Estimated

Average Volume per

Event million gallons million gallons million gallons

 Actual or  Estimated  Actual or  Estimated  Actual or  Estimated

Minimum Rainfall Causing

a CSO Event in Last Year inches of rainfall inches of rainfall inches of rainfall

 Actual or  Estimated  Actual or  Estimated  Actual or  EstimatedEPA Form 3510-2A (Revised <INSERT DATE>) Page 12 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 ImplementationCSO Receiving Waters 5.7 Provide the information in the table below for each of your CSO outfalls.

CSO Outfall Number ____ CSO Outfall Number ____ CSO Outfall Number ____

Receiving Water Name

Name of Watershed / Stream System

U.S. Soil Conservation Service 14-digit

Watershed Code (if known)  Unknown  Unknown  Unknown

Name of State Management / River

Basin U.S. Geological Survey 8- Digit Hydrologic Cataloging Unit Code (if known)  Unknown  Unknown  Unknown

Description of Known Water Quality Impacts on Receiving Stream by CSO (See Instructions for examples.)

SECTION 6. CHECKLIST AND CERTIFICATION STATEMENTChecklist and Certification Statement 6.1 In Column 1 below, mark the Form 2A sections you have completed. Specify the attachments you are enclosing with

each section in Column 2.

Column 1  Column 2



##  Section 1 

##  w/attachments


##  Section 2 

##  w/topographic map 

##  w/process flow diagram


##  w/additional attachments


##  Section 3 

##  w/Table A 

##  w/Table D



##  w/Table B 

##  w/Table E



##  w/Table C 

##  w/additional attachments


##  Section 4 

##  w/SIU and CIU attachments 

##  w/Table F



##  w/additional attachments



##  Section 5 

##  w/CSO map 

##  w/additional attachments


##  w/CSO system diagram


##  Section 6

6.2 Certification Statement

I certify under penalty of law that this document and all atta chments were prepared under my direction or supervision in accordance with a system designed to assure that qualif ied personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or 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

Signature Date SignedEPA Form 3510-2A (Revised <INSERT DATE>)Page 13EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE A. EFFLUENT PARAMETERS FOR ALL POTWSPollutantMaximum Daily DischargeAverage Daily DischargeAnalyticalMethod1ML or MDL(include units)ValueUnitsValueUnitsNumber ofSamplesBiochemical Oxygen Demand(BOD5or CBOD5)MLMDLFecal ColiformMLMDLDesign FlowMLMDLpH (minimum)MLMDLpH(maximum)MLMDLTemperature (winter)MLMDLTemperature(summer)MLMDLTotal Suspended Solids (TSS)MLMDL1Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136for the analysis of pollutants or pollutant parameters orrequired under 40 CFR chapter I, subchapter Nor O. See Instructions and 40 CFR 122.21(e)(3).ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationThis page intentionally left blank.EPA Form 3510-2A (Revised <INSERT DATE>)Page 15EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE B. EFFLUENT PARAMETERS FOR ALL POTWS WITHA FLOW EQUAL TO OR GREATER THAN 0.1 MGD.PollutantMaximum Daily DischargeAverage Daily DischargeAnalyticalMethod1ML or MDL(include units)ValueUnitsValueUnitsNumber ofSamplesAmmonia(asN)MLMDLChlorine(Total Residual, TRC)2MLMDLDissolvedOxygenMLMDLNitrate/NitriteMLMDLKjeldahlNitrogenMLMDLOilandGreaseMLMDLPhosphorusMLMDLTotalDissolvedSolidsMLMDL1Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136for the analysis of pollutants or pollutant parameters orrequired under 40 CFR chapter I, subchapter N orO. See Instructions and 40 CFR 122.21(e)(3).2Facilities that do not use chlorine for disinfection, do not use chlorine elsewhere in the treatment process, and have no reasonable potential to discharge chlorine in their effluent are notrequired to report data for chlorine..ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationThis page intentionally left blank.EPA Form 3510-2A (Revised <INSERT DATE>)Page 17EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWSPollutantMaximum Daily DischargeAverage Daily DischargeAnalyticalMethod1ML or MDL(include units)ValueUnitsValueUnitsNumber ofSamplesMetals, Cyanide, and Total PhenolsHardness (as CaCO3)MLMDLAntimony,TotalRecoverableMLMDLArsenic,TotalRecoverableMLMDLBeryllium,TotalRecoverableMLMDLCadmium,TotalRecoverableMLMDLChromium,TotalRecoverableMLMDLCopper,TotalRecoverableMLMDLLead,TotalRecoverableMLMDLMercury,TotalRecoverableMLMDLNickel,TotalRecoverableMLMDLSelenium,TotalRecoverableMLMDLSilver,TotalRecoverableMLMDLThallium,TotalRecoverableMLMDLZinc,TotalRecoverableMLMDLCyanideMLMDLTotalPhenolicCompoundsMLMDLVolatile Organic CompoundsAcroleinMLMDLAcrylonitrileMLMDLBenzeneMLMDLBromoformMLMDLEPA Form 3510-2A (Revised <INSERT DATE>)Page 18EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWSPollutantMaximum Daily DischargeAverage Daily DischargeAnalyticalMethod1ML or MDL(include units)ValueUnitsValueUnitsNumber ofSamplesCarbonTetrachlorideMLMDLChlorobenzeneMLMDLChlorodibromomethaneMLMDLChloroethaneMLMDL2-ChloroethylvinylEtherMLMDLChloroformMLMDLDichlorobromomethaneMLMDL1,1-DichloroethaneMLMDL1,2-DichloroethaneMLMDLtrans-1,2-DichloroethyleneMLMDL1,1-DichloroethyleneMLMDL1,2-DichloropropaneMLMDL1,3-DichloropropyleneMLMDLEthylbenzeneMLMDLMethylBromideMLMDLMethylChlorideMLMDLMethyleneChlorideMLMDL1,1,2,2-TetrachloroethaneMLMDLTetrachloroethyleneMLMDLTolueneMLMDL1,1,1-TrichloroethaneMLMDL1,1,2-TrichloroethaneMLMDLEPA Form 3510-2A (Revised <INSERT DATE>)Page 19EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWSPollutantMaximum Daily DischargeAverage Daily DischargeAnalyticalMethod1ML or MDL(include units)ValueUnitsValueUnitsNumber ofSamplesTrichloroethyleneMLMDLVinylChlorideMLMDLAcid-Extractable Compoundsp-Chloro-m-CresoMLMDL2-ChlorophenolMLMDL2,4-DichlorophenolMLMDL4,6-Dinitro-o-CresolMLMDL2,4-DinitrophenolMLMDL2-NitrophenolMLMDL4-NitrophenolMLMDLPentachlorophenolMLMDLPhenolMLMDL2,4,6-TrichlorophenolMLMDLBase-Neutral CompoundsAcenaphtheneMLMDLAcenaphthyleneMLMDLAnthraceneMLMDLBenzidineMLMDLBenzo(a)anthraceneMLMDLBenzo(a)pyreneMLMDL3,4-BenzofluorantheneMLMDLBenzo(ghi)peryleneMLMDLEPA Form 3510-2A (Revised <INSERT DATE>)Page 20EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWSPollutantMaximum Daily DischargeAverage Daily DischargeAnalyticalMethod1ML or MDL(include units)ValueUnitsValueUnitsNumber ofSamplesBenzo(k)fluorantheneMLMDLBis(2-Chloroethoxy)MethaneMLMDLBis(2-Chloroethyl)EtherMLMDLBis(2-Chloroisopropyl)EtherMLMDLBis(2-Ethylhexyl)PhthalateMLMDL4-BromophenylPhenylEtherMLMDLButylBenzylPhthalateMLMDL2-ChloronaphthaleneMLMDL4-ChlorophenylPhenylEtherMLMDLChryseneMLMDLdi-n-ButylPhthalateMLMDLdi-n-OctylPhthalateMLMDLDibenzo(a,h)anthraceneMLMDL1,2-DichlorobenzeneMLMDL1,3-DichlorobenzeneMLMDL1,4-DichlorobenzeneMLMDL3,3-DichlorobenzidineMLMDLDiethylPhthalateMLMDLDimethylPhthalateMLMDL2,4-DinitrotolueneMLMDL2,6-DinitrotolueneMLMDL1,2-DiphenylhydrazineMLMDLEPA Form 3510-2A (Revised <INSERT DATE>)Page 21EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE C. EFFLUENT PARAMETERS FOR SELECTED POTWSPollutantMaximum Daily DischargeAverage Daily DischargeAnalyticalMethod1ML or MDL(include units)ValueUnitsValueUnitsNumber ofSamplesFluorantheneMLMDLFluoreneMLMDLHexachlorobenzeneMLMDLHexachlorobutadieneMLMDLHexachlorocyclo-pentadieneMLMDLHexachloroethaneMLMDLIndeno(1,2,3-cd)pyreneMLMDLIsophoroneMLMDLNaphthaleneMLMDLNitrobenzeneMLMDLN-nitrosodi-n-propylamineMLMDLN-nitrosodimethylamineMLMDLN-nitrosodiphenylamineMLMDLPhenanthreneMLMDLPyreneMLMDL1,2,4-TrichlorobenzeneMLMDL1Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136for the analysis of pollutants or pollutant parameters orrequired under 40 CFR chapter I, subchapter Nor O. See Instructions and 40 CFR 122.21(e)(3).EPA Form 3510-2A (Revised <INSERT DATE>)Page 22EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE D. ADDITIONAL POLLUTANTS AS REQUIRED BY NPDES PERMITTING AUTHORITYPollutant(list)Maximum Daily DischargeAverage Daily DischargeAnalyticalMethod1ML or MDL(include units)ValueUnitsValueUnitsNumber ofSamplesNo additional sampling is required by NPDES permitting authority.MLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDLMLMDL1Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR Part 136for the analysis of pollutants or pollutant parameters orrequired under 40 CFR chapter I, subchapter Nor O. See Instructions and 40 CFR 122.21(e)(3).ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationThis page intentionally left blank.EPA Form 3510-2A (Revised <INSERT DATE>)Page 24EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE E. EFFLUENT MONITORINGFOR WHOLE EFFLUENT TOXICITYThe table provides response space for one whole effluent toxicity sample. Copy the table to report additional test results.Test InformationTest Number _____Test Number _____Test Number _____TestSpeciesAge at Initiation of TestOutfallNumberDate Sample CollectedDate Test StartedDurationToxicity Test MethodsTest Method NumberManualTitleEdition Number and Year of PublicationPageNumber(s)Sample TypeSample Type(check one)Grab24-Hour CompositeGrab24-Hour CompositeGrab24-Hour CompositeSample LocationSample Location(check one)Before DisinfectionAfter DisinfectionAfter DechlorinationBefore DisinfectionAfter DisinfectionAfter DechlorinationBefore DisinfectionAfter DisinfectionAfter DechlorinationPoint in Treatment ProcessDescribe the point in the treatment processat which the sample was collected for eachtest.Toxicity TypeIndicate for each test whether the test wasperformed to asses acute or chronic toxicity,or both.(Check one response.)AcuteChronicBothAcuteChronicBothAcuteChronicBothEPA Form 3510-2A (Revised <INSERT DATE>)Page 25EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE E. EFFLUENT MONITORINGFOR WHOLE EFFLUENT TOXICITYThe table provides response space for one whole effluent toxicity sample. Copy the table to report additional test results.Test Number _____Test Number _____Test Number _____Test TypeIndicate the type of test performed.(Check oneresponse.)StaticStatic-renewalFlow-throughStaticStatic-renewalFlow-throughStaticStatic-renewalFlow-throughSource of Dilution WaterIndicate the source of dilution water.(Checkone response.)Laboratory WaterReceiving WaterLaboratory WaterReceiving WaterLaboratory WaterReceiving WaterIf laboratory water, specify type.If receiving water, specify source.Type of Dilution WaterIndicate the type of dilution water. If saltwater, specify “natural” or type of artificialsea salts or brine used.Fresh WaterSalt Water(specify)Fresh WaterSalt Water(specify)Fresh WaterSalt Water(specify)Percentage Effluent UsedSpecify the percentage effluent used for allconcentrations in the test series.Parameters TestedCheck the parameters tested.pHSalinityTemperatureAmmoniaDissolved OxygenpHSalinityTemperatureAmmoniaDissolved OxygenpHSalinityTemperatureAmmoniaDissolved OxygenAcute Test ResultsPercent Survival in 100% Effluent% % %LC5095% Confidence Interval% % %Control percent survival% % %EPA Form 3510-2A (Revised <INSERT DATE>)Page 26EPA Identification NumberNPDES Permit NumberFacility NameOutfall NumberForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE E. EFFLUENT MONITORINGFOR WHOLE EFFLUENT TOXICITYThe table provides response space for one whole effluent toxicity sample. Copy the table to report additional test results.Test Number _____Test Number _____Test Number _____Acute Test Results ContinuedOther(describe)Chronic Test ResultsNOEC% % %IC25% % %Control Percent Survival% % %Other(describe)Quality Control/Quality AssuranceIs reference toxicant data available?YesNoYesNoYesNoWas reference toxicant test withinacceptable bounds?YesNoYesNoYesNoWhat date was reference toxicant test run(MM/DD/YYYY)?Other(describe)ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationThis page intentionally left blank.EPA Form 3510-2A (Revised <INSERT DATE>)Page 28EPA Identification NumberNPDES Permit NumberFacility NameForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE F. INDUSTRIAL DISCHARGE INFORMATIONResponse space is provided for three SIUsor CIUs. Copy the table to report information for additional SIUs and CIUs.SIU _____orCIU _____SIU _____orCIU _____SIU _____orCIU _____Name of SIU or CIUMailing Address (street or P.O. Box)City, State and ZIP CodeProvide a description of all industrial processesthat affect or contribute to the SIU’s or CIU’sdischarge and SIC or NAICS code(s), if available.List the principal products and raw materials thataffect or contribute to the SIU’s or the CIU’sdischarge.Indicate the average daily volume of wastewaterdischarged by the SIU or the CIU.gpd gpd gpdHow much of the average daily volume isattributable to process flow?gpd gpd gpdHow much of the average daily volume isattributable to non-process flow?gpd gpd gpdIs the SIU or the CIU subject to local limits?YesNoYesNoYesNoIs the SIU subject to categorical standards?YesNoYesNoYesNoEPA Form 3510-2A (Revised <INSERT DATE>)Page 29EPA Identification NumberNPDES Permit NumberFacility NameForm ApprovedOMB No. <INSERT NO.>Form Expires <INSERT DATE>ContainsNonbindingRecommendationsDraftApplicationForms–NotforImplementationTABLE F. INDUSTRIAL DISCHARGE INFORMATIONResponse space is provided for three SIUsor CIUs. Copy the table to report information for additional SIUs and CIUs.SIU _____orCIU _____SIU _____orCIU _____SIU _____orCIU _____Under what categories and subcategories is theSIU or the CIU subject?Has the POTW experienced problems (e.g.,upsets, pass-through interferences, etc.) in thepast 4.5 years that are attributable to the SIU orCIU?YesNoYesNoYesNoIf yes, describe.