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United States 

Environmental Protection 

Agency 

Office of 

Enforcement 

Washington, DC 20460 

EPA Form 3510-1 

Revised August 1990 

Permits Division 

Application Form 1 – General 

Information 

Consolidated Permits Program 

This form must be completed by all persons applying for a 

permit under EPA’s Consolidated Permits Program. See 

the general instructions to Form 1 to determine which 

other application forms you will need. 
1-1

DESCRIPTION OF CONSOLIDATED 

PERMIT APPLICATION FORMS 

FORM 1 PACKAGE 

TABLE OF CONTENTS 

The Consolidated Permit Application Forms are: 

Form 1 – General Information (included in this part); 

Form 2 – Discharges to Surface Water (NPDES Permits): 

2A. Publicly owned Treatment Works (Reserved - not included in 

this package), 

2B. Concentrated Animal Feeding Operations and Aquatic Animal 

Production Facilities (not included in this package), 

2C. Existing Manufacturing, Commercial, Mining, and Silvicultural 

Operations (not included in this package), and 

2D. New Manufacturing, Commercial, Mining, and Silvicultural 

Operations (Reserved - not included in this package); 

Form 3 – Hazardous Waste Application Form (RCRA Permits - not 

included in this package); 

Form 4 – Underground Injection of Fluids (UIC Permits - Reserved - 

not included in this package); and 

Form 5 – Air Emissions in Attainment Areas (PSD Permits - Reserved - not included in this package). 

Section A. General Instructions 

Section B. Instructions for Form 1 

Section C. Activities Which Do Not Require Permits 

Section D. Glossary 

Form 1 (two copies)

SECTION A – GENERAL INSTRUCTIONS 

Who Must Apply 

With the exceptions described in Section C of these instructions, 

Federal laws prohibit you from conducting any of the following activities without a permit. 

NPDES (National Pollutant Discharge Elimination System Under the 

Clean Water Act, 33 U.S.C. 1251). Discharge of pollutants into the 

waters of the United States. 

RCRA (Resource Conservation and Recovery Act, 42 U.S.C. 6901). 

Treatment, storage, or disposal of hazardous wastes. 

UIC (Underground Injection Control Under the Safe Drinking Water 

Act, 42 U.S.C. 300f). Injection of fluids underground by gravity flow 

or pumping. 

PSD (Prevention of Significant Deterioration Under the Clean Air Act, 

72 U.S.C 7401). Emission of an air pollutant by a new or modified 

facility in or near an area which has attained the National Ambient Air 

Quality Standards for that pollutant. 

Each of the above permit programs is operated in any particular 

State by either the United States Environmental Protection Agency 

(EPA) or by an approved State agency. You must use this application form to apply for a permit for those programs administered by 

EPA. For those programs administered by approved states, contact 

the State environmental agency for the proper forms. 

If you have any questions about whether you need a permit under 

any of the above programs, or if you need information as to whether 

a particular program is administered by EPA or a State agency, or if 

you need to obtain application forms, contact your EPA Regional 

office (listed in Table 1). 

Upon your request, and based upon information supplied by you, 

EPA will determine whether you are required to obtain a permit for a 

particular facility. Be sure to contact EPA if you have a question, 

because Federal laws provide that you may be heavily penalized if 

you do not apply for a permit when a permit is required. 

Form 1 of the EPA consolidated application forms collects general 

information applying to all programs. You must fill out Form 1 regardless of which permit you are applying for. In addition, you must fill out 

one of the supplementary forms (Forms 2 – 5) for each permit 

needed under each of the above programs. Item II of Form 1 will 

guide you to the appropriate supplementary forms. 

You should note that there are certain exclusions to the permit requirements listed above. The exclusions are described in detail In 

Section C of these instructions. If your activities are excluded from 

permit requirements then you do not need to complete and return 

any forms. 

NOTE: Certain activities not listed above also are subject to EPA 

administered environmental permit requirements. These include 

permits for ocean dumping, dredged or fill material discharging, and 

certain types of air emissions. Contact your EPA Regional office for 

further information. 

Table 1. Addresses of EPA Regional Contacts and States Within 

the Regional Office Jurisdictions 

REGION 1 

Permit Contact, Environmental and Economic Impact Office, U.S. 

Environmental Protection Agency, 1 Congress St., Suite 1100, 

Boston, MA 02114-2023, Phone: (617) 918-1111, Fax: (617) 918-

1809, Toll free within Region 1: (888) 372-7341, 

http://www.epa.gov/region01/. 

Connecticut, Maine, Massachusetts, New Hampshire, 

Rhode Island, and Vermont. 

REGION 2 

Permit Contact, Permits Administration Branch, U.S. Environmental Protection Agency, 290 Broadway, New York, NY 10007-

1866, Phone: (212) 637-3000, Fax: (212) 637-3526, 

http://www.epa.gov/region02/. 

New Jersey, New York, Virgin Islands, and Puerto Rico. 

REGION 3 

Permit Contact (3 EN 23), U.S. Environmental Protection Agency, 

1650 Arch Street, Philadelphia, PA 19103-2029, Phone: (215) 

814-5000, Fax: (215) 814-5103, Toll free: (800) 438-2474, 

http://www.epa.gov/region03/. 

Delaware, District of Columbia, Maryland, Pennsylvania, 

Virginia, and West Virginia. 
SECTION A – GENERAL INSTRUCTIONS 

1-2

REGION 4 

Permit Contact, Permits Section, U.S. Environmental Protection 

Agency, Atlanta Federal Center, 61 Forsyth Street, SW, Atlanta, 

GA 30303-3104, Phone: (404) 562-9900, Fax: (404) 562-8174, 

Toll free: (800) 241-1754, http://www.epa.gov/region04/. 

Alabama, Florida, Georgia, Kentucky, Mississippi, 

North Carolina, South Carolina, and Tennessee. 

REGION 5 

Permit Contact (5EP), U.S. Environmental Protection Agency, 77 

West Jackson Boulevard, Chicago, IL 60604-3507, Phone: (312) 

353-2000, Fax: (312) 353-4135, Toll free within Region 5: (800) 

621-8431, http://www.epa.gov/region5/. 

Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. 

REGION 6 

Permit Contact (6AEP), U.S. Environmental Protection Agency, 

Fountain Place 12th Floor, Suite 1200, 1445 Ross Avenue, Dallas, 

TX 75202-2733, Phone: (214) 665-2200, Fax: (214) 665-7113, 

Toll free within Region 6: (800) 887-6063, 

http://www.epa.gov/region06/. 

Arkansas, Louisiana, New Mexico, Oklahoma, and Texas. 

REGION 7 

Permit Contact, Permits Branch, U.S. Environmental Protection 

Agency, 901 North 5th Street, Kansas City, KS 66101, Phone: 

(913) 551-7003, Toll free: (800) 223-0425, 

http://www.epa.gov/region07/. 

Iowa, Kansas, Missouri, and Nebraska. 

REGION 8 

Permit Contact (8E-WE), U.S. Environmental Protection Agency, 

999 18th Street, Suite 500, Denver, CO 80202-2466, Phone: (303) 

312-6312, Fax: (303) 312-6339, Toll free: (800) 227-8917, 

http://www.epa.gov/region08/. 

Colorado, Montana, North Dakota, South Dakota, Utah, and 

Wyoming. 

REGION 9 

Permit Contact, Permits Branch (E-4), U.S. Environmental Protection Agency, 75 Hawthorne Street, San Francisco, CA 94105, 

Phone: (415) 947-8000, Fax: (415) 947-3553, Toll free within Region 9: (866) EPA-WEST, http://www.epa.gov/region09/. 

Arizona, California, Hawaii, Nevada, Guam, American Samoa, 

and Trust Territories. 

REGION 10 

Permit Contact (M/S 521), U.S. Environmental Protection Agency, 

1200 Sixth Avenue, Seattle, WA 98101, Phone: (206) 553-1200, 

Fax: (206) 553-2955, Toll free: (800) 424-4372, 

http://www.epa.gov/region10/. 

Alaska, Idaho, Oregon, and Washington. 

Where to File 

The application forms should be mailed to the EPA Regional office 

whose Region includes the State in which the facility is located (see 

Table 1). 

If the State in which the facility is located administers a Federal 

permit program under which you need a permit, you should contact 

the appropriate State agency for the correct forms. Your EPA Regional office (Table 1) can tell you to whom to apply and can provide 

the appropriate address and phone number. 

When to File 

Because of statutory requirements, the deadlines for filing applications vary according to the type of facility you operate and the type of 

permit you need. These deadlines are as follows:1 

Table 2. Filing Dates for Permits 

FORM (permit) WHEN TO FILE 

2A (NPDES) . . . . . . . . . . 180 days before your present NPDES permit expires. 

2B (NPDES) . . . . . . . . . . 180 days before your present NPDES permit expires2, 

or 180 days prior to startup if you are a new facility. 

2C (NPDES) . . . . . . . . . . 180 days before your present NPDES permit expires2

. 

2D (NPDES) . . . . . . . . . . 180 days prior to startup. 

3 (Hazardous Waste) . . . Existing facility: Six months following publication of 

regulations listing hazardous wastes. 

New facility: 180 days before commencing physical 

construction. 

4 (UIC) . . . . . . . . . . . . . . A reasonable time prior to construction for new wells; 

as directed by the Director for existing wells. 

5 (PSD). . . . . . . . . . . . . Prior to commencement of construction. 

1 Please note that some of these forms are not yet available for use and are listed 

as “Reserved” at the beginning of these instructions. Contact your EPA Regional 

office for information on current application requirements and forms. 

2 If your present permit expires on or before November 30, 1980, the filing date is 

the date on which your permit expires. If your permit expires during the period 

December 1, 1980–May 31, 1981, the filing date is 90 days before your permit 

expires.

Federal regulations provide that you may not begin to construct a 

new source in the NPDES program, a new hazardous waste management facility, a new injection well, or a facility covered by the 

PSD program before the issuance of a permit under the applicable 

program. Please note that if you are required to obtain a permit 

before beginning construction, as described above, you may need to 

submit your permit application well in advance of an applicable 

deadline listed in Table 2. 

Fees 

The U.S. EPA does not require a fee for applying for any permit 

under the consolidated permit programs. (However, some States 

which administer one or more of these programs require fees for the 

permits which they issue.) 

Availability of Information to Public 

Information contained in these application forms will, upon request, 

be made available to the public for inspection and copying. However, 

you may request confidential treatment for certain information which 

you submit on certain supplementary forms. The specific instructions 

for each supplementary form state what information on the form, if 

any, may be claimed as confidential and what procedures govern the 

claim. No information on Forms 1 and 2A through 2D may be 

claimed as confidential. 

Completion of Forms 

Unless otherwise specified in instructions to the forms, each item in 

each form must be answered. To indicate that each item has been 

considered, enter “NA,” for not applicable, if a particular item does 

not fit the circumstances or characteristics of your facility or activity. 

If you have previously submitted information to EPA or to an approved State agency which answers a question, you may either 

repeat the information in the space provided or attach a copy of the 

previous submission. Some items in the form require narrative explanation. If more space is necessary to answer a question, attach a 

separate sheet entitled “Additional Information.” 

Financial Assistance for Pollution Control 

There are a number of direct loans, loan guarantees, and grants 

available to firms and communities for pollution control expenditures. 

These are provided by the Small Business Administration, the Economic Development Administration, the Farmers Home Administration, and the Department of Housing and Urban Development, Each 

EPA Regional office (Table 1) has an economic assistance coordinator who can provide you with additional information. 

EPA’s construction grants program under Title II of the Clean Water 

Act is an additional source of assistance to publicly owned treatment 

works. Contact your EPA Regional office for details. 
SECTION B – FORM 1 LINE BY LINE INSTRUCTIONS 

1-3

This form must be completed by all applicants. 

Completing This Form 

Please type or print in the unshaded areas only. Some items have 

small graduation marks in the fill-in spaces. These marks indicate the 

number of characters that may be entered into our data system. The 

marks are spaced at 1/6" intervals which accommodate elite type (12 

characters per inch). If you use another type you may ignore the 

marks. If you print, place each character between the marks. Abbreviate if necessary to stay within the number of characters allowed for 

each item. Use one space for breaks between words, but not for 

punctuation marks unless they are needed to clarify your response. 

Item I 

Space is provided at the upper right hand corner of Form 1 for insertion of your EPA Identification Number. If you have an existing facility, enter your Identification Number. If you don’t know your EPA 

Identification Number, please contact your EPA Regional office 

(Table 1), which will provide you with your number. If your facility is 

new (not yet constructed), leave this item blank.

Item II 

Answer each question to determine which supplementary forms you 

need to fill out. Be sure to check the glossary in Section D of these 

instructions for the legal definitions of the bold faced words. Check 

Section C of these instructions to determine whether your activity is 

excluded from permit requirements. 

If you answer “no” to every question, then you do not need a permit, 

and you do not need to complete and return any of these forms. 

If you answer “yes” to any question, then you must complete and file 

the supplementary form by the deadline listed in Table 2 along with 

this form. (The applicable form number follows each question and is 

enclosed in parentheses.) You need not submit a supplementary 

form if you already have a permit under the appropriate Federal 

program, unless your permit is due to expire and you wish to renew 

your permit. 

Questions (I) and (J) of Item II refer to major new or modified 

sources subject to Prevention of Significant Deterioration (PSD) 

requirements under the Clean Air Act. For the purpose of the PSD 

program, major sources are defined as: (A) Sources listed in Table 3 

which have the potential to emit 100 tons or more per year emissions; and (B) All other sources with the potential to emit 250 tons or 

more per year. See Section C of these instructions for discussion of 

exclusions of certain modified sources. 

Table 3. 28 Industrial Categories Listed In Section 169(1) of the 

Clean Air Act of 1977 

Fossil fuel-fired steam generators of more than 250 million BTU per 

hour heat input; 

Coal cleaning plants (with thermal dryers); 

Kraft pulp mills; 

Portland cement plants; 

Primary zinc smelters; 

Iron and steel mill plants; 

Primary aluminum ore reduction plants; 

Primary copper smelters; 

Municipal incinerators capable of charging more than 250 tons of 

refuse per day; 

Hydrofluoric acid plants; 

Nitric acid plants; 

Sulfuric acid plants; 

Petroleum refineries; 

Lime plants; 

Phosphate rock processing plants; 

Coke oven batteries; 

Sulfur recovery plants; 

Carbon black plants (furnace process); 

Primary lead smelters; 

Fuel conversion plants; 

Sintering plants; 

Secondary metal production plants; 

Chemical process plants; 

Fossil fuel boilers (or combination thereof) totaling more than 250 

million BTU per hour heat input; 

Table 3 (continued) 

Petroleum storage and transfer units with a total storage capacity 

exceeding 300,000 barrels; 

Taconite ore processing plants; 

Glass fiber processing plants; and 

Charcoal production plants.

Item III 

Enter the facility’s official or legal name. Do not use a colloquial name. 

Item IV 

Give the name, title, and work telephone number of a person who is 

thoroughly familiar with the operation of the facility and with the facts 

reported in this application and who can be contacted by reviewing 

offices if necessary. 

Item V 

Give the complete mailing address of the office where correspondence should be sent. This often is not the address used to designate the location of the facility or activity.

Item VI

Give the address or location of the facility identified in Item III of this 

form. 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 Rts. 425 and 22). 

Item VII 

List, in descending order of significance, the four 4-digit standard 

industrial classification (SIC) codes which best describe your facility 

in terms of the principal products or services you produce or provide. 

Also, specify each classification in words. These classifications may 

differ from the SIC codes describing the operation generating the 

discharge, air emissions, or hazardous wastes. 

SIC code numbers are descriptions which may be found in the 

“Standard Industrial Classification Manual” prepared by the Executive Office of the President, Office of Management and Budget, 

which is available from the Government Printing Office, Washington, 

D.C. Use the current edition of the manual. If you have any questions 

concerning the appropriate SIC code for your facility, contact your 

EPA Regional office (see Table 1). 

Item VIII-A 

Give the name, as it is legally referred to, of the person, firm, public 

organization, or any other entity which operates the facility described 

in this application. This may or may not be the same name as the 

facility. The operator of the facility is the legal entity which controls 

the facility’s operation rather than the plant or site manager. Do not 

use a colloquial name. 

Item VIII-B 

Indicate whether the entity which operates the facility also owns it by 

marking the appropriate box. 

Item VIII-C 

Enter the appropriate letter to indicate the legal status of the operator 

of the facility. Indicate “public” for a facility solely owned by local 

government(s) such as a city, town, county, parish, etc. 

Items VIII-D-H 

Enter the telephone number and address of the operator identified in 

Item VIII-A. 

Item IX 

Indicate whether the facility is located on Indian Lands. 

Item X 

Give the number of each presently effective permit issued to the 

facility for each program or, if you have previously filed an application 

but have not yet received a permit, give the number of the application, if any. Fill in the unshaded area only. If you have more than one 

currently effective permit for your facility under a particular permit 

program, you may list additional permit numbers on a separate sheet 

of paper. List any relevant environmental Federal (e.g., permits 
SECTION B – FORM 1 LINE BY LINE INSTRUCTIONS 

1-4

under the Ocean Dumping Act, Section 404 of the Clean Water Act 

or the Surface Mining Control and Reclamation Act), State (e.g., 

State permits for new air emission sources in nonattainment areas 

under Part D of the Clean Air Act or State permits under Section 404 

of the Clean Water Act), or local permits or applications under 

“other.” 

Item XI 

Provide a topographic map or maps of the area extending at least to 

one mile beyond the property boundaries of the facility which clearly 

show the following: 

The legal boundaries of the facility; 

The location and serial number of each of your existing and proposed intake and discharge structures; 

All hazardous waste management facilities; 

Each well where you inject fluids underground; and 

All springs and surface water bodies in the area, plus all drinking 

water wells within 1/4 mile of the facility which are identified in the 

public record or otherwise known to you. 

If an intake or discharge structure, hazardous waste disposal site, or 

injection well associated with the facility is located more than one 

mile from the plant, include it on the map, if possible. If not, attach 

additional sheets describing the location of the structure, disposal 

site, or well, and identify the U.S. Geological Survey (or other) map 

corresponding to the location. 

On each map, include the map scale, a meridian arrow showing 

north, and latitude and longitude at the nearest whole second. On all 

maps of rivers, show the direction of the current, and in tidal waters, 

show the directions of the ebb and flow tides. Use a 7-1/2 minute 

series map published by the U.S. Geological Survey, which may be 

obtained through the U.S. Geological Survey Offices listed below, If 

a 7-1/2 minute series map has not been published for your facility 

site, then you may use a 15 minute series map from the U.S. Geological Survey. If neither a 7-1/2 nor 15 minute series map has been 

published for your facility site, use a plat map or other appropriate 

map, including all the requested information; in this case, briefly 

describe land uses in the map area (e.g., residential, commercial). 

You may trace your map from a geological survey chart, or other 

map meeting the above specifications. If you do, your map should 

bear a note showing the number or title of the map or chart it was 

traced from. Include the names of nearby towns, water bodies, and 

other prominent points. An example of an acceptable location map is 

shown in Figure 1-1 of these instructions. (NOTE: Figure 1-1 is 

provided for purposes of illustration only, and does not represent any 

actual facility.) 

U.S.G.S. OFFICES AREA SERVED 

Eastern Mapping Center 

National Cartographic Information Center 

U.S.G.S. 

536 National Center 

Reston, VA 22092 

Phone No. (703) 860-6336 

Ala., Conn., Del., D.C., Fla., 

Ga., Ind., Ky., Maine, Md., 

Mass., N.H., N.J., N.Y., N.C., 

S.C., Ohio, Pa., Puerto Rico, 

R.I., Tenn., Vt., Va., W. Va., 

and Virgin Islands 

Mid Continent Mapping Center 

National Cartographic Information Center 

U.S.G.S. 

1400 Independence Road 

Rolla, MO 65401 

Phone No. (314) 341-0851 

Ark.. Ill., Iowa, Kans., La., 

Mich., Minn., Miss., Mo., 

N. Dak., Nebr., Okla., S. Dak., 

and Wis. 

Rocky Mountain Mapping Center 

National Cartographic Information Center 

U.S.G.S. 

Stop 504, Box 25046 Federal Center 

Denver, CO 80225 

Phone No. (303) 234-2326 

Alaska, Colo., Mont., N. Mex., 

Tex., Utah, and Wyo. 

Western Mapping Center 

National Cartographic Information Center 

U.S.G.S. 

345 Middlefield Road 

Menlo Park, CA 94025 

Phone No. (415) 323-8111 

Ariz., Calif., Hawaii, Idaho, 

Nev., Oreg., Wash., American 

Samoa, Guam, and Trust 

Territories 

Item XII 

Briefly describe the nature of your business (e.g., products produced 

or services provided). 

Item XIII 

Federal statues provide for severe penalties for submitting false 

information on this application form. 

18 U.S.C. Section 1001 provides that “Whoever, in any matter within 

the jurisdiction of any department or agency of the United States 

knowingly and willfully falsifies, conceals or covers up by any trick, 

scheme, or device a material fact, or makes or uses any false writing 

or document knowing some to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or 

imprisoned not more than five years, or both.” 

Section 309(c)(2) of the Clean Water Act and Section 113(c)(2) of 

the Clean Air Act each provide 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.” 

In addition, Section 3008(d)(3) of the Resource Conservation and 

Recovery Act provides for a fine up to $25,000 per day or imprisonment up to one year, or both, for a first conviction for making a false 

statement in any application under the Act, and for double these 

penalties upon subsequent convictions. 

FEDERAL REGULATIONS REQUIRE THIS APPLICATION TO BE 

SIGNED AS FOLLOWS: 

A. For a corporation, by a principal executive officer of at least the 

level of vice president. However, if the only activity in Item II which 

is marked “yes” is Question G, the officer may authorize a person 

having responsibility for the overall operations of the well or well 

field to sign the certification. In that case, the authorization must 

be written and submitted to the permitting authority. 

B. For partnership or sole proprietorship, by a general partner or 

the proprietor, respectively; or 

C. For a municipality, State, Federal, or other public facility, by either a principal executive officer or ranking elected official. 
SECTION C – ACTIVITIES WHICH DO NOT REQUIRE PERMITS 

1-5

1. National Pollutant Discharge Elimination System Permits 

Under the Clean Water Act. You are not required to obtain an 

NPDES permit if your discharge is in one of the following categories, 

as provided by the Clean Water Act (CWA) and by the NPDES 

regulations (40 CFR Parts 122-125). However, under Section 510 of 

CWA a discharge exempted from the federal NPDES requirements 

may still be regulated by a State authority; contact your State environmental agency to determine whether you need a State permit. 

A. DISCHARGES FROM VESSELS. Discharges of sewage from 

vessels, effluent from properly functioning marine engines, laundry, shower, and galley sink wastes, and any other discharge incidental to the normal operation of a vessel do not require NPDES 

permits. However, discharges of rubbish, trash, garbage, or other 

such materials discharged overboard require permits, and so do 

other discharges when the vessel is operating in a capacity other 

than as a means of transportation, such as when the vessel is being used as an energy or mining facility, a storage facility, or a 

seafood processing facility, or is secured to the bed of the ocean, 

contiguous zone, or waters of the United States for the purpose of 

mineral or oil exploration or development. 

B. DREDGED OR FILL MATERIAL. Discharges of dredged or fill 

material into waters of the United States do not need NPDES 

permits if the dredging or filling is authorized by a permit issued by 

the U.S. Army Corps of Engineers or an EPA approved State under Section 404 of CWA. 

C. DISCHARGES INTO PUBLICLY OWNED TREATMENT 

WORKS (POTW), The introduction of sewage, industrial wastes, 

or other pollutants into a POTW does not need an NPDES permit. 

You must comply with all applicable pretreatment standards 

promulgated under Section 307(b) of CWA, which may be included in the permit issued to the POTW. If you have a plan or an 

agreement to switch to a POTW in the future, this does not relieve 

you of the obligation to apply for and receive an NPDES permit 

until you have stopped discharging pollutants into waters of the 

United States. 

(NOTE: Dischargers into privately owned treatment works do not 

have to apply for or obtain NPDES permits except as otherwise 

required by the EPA Regional Administrator. The owner or operator of the treatment works itself, however, must apply for a permit 

and identify all users in its application. Users so identified will receive public notice of actions taken on the permit for the treatment 

works.) 

D. DISCHARGES FROM AGRICULTURAL AND SILVICULTURAL ACTIVITIES. Most discharges from agricultural and silvicultural activities to waters of the United States do not require 

NPDES permits. These include runoff from orchards, cultivated 

crops, pastures, range lands, and forest lands. However, the discharges listed below do require NPDES permits. Definitions of the 

terms listed below are contained in the Glossary section of these 

instructions. 

1. Discharges from Concentrated Animal Feeding Operations. 

(See Glossary for definitions of “animal feeding operations” and 

“concentrated animal feeding operations.” Only the latter require 

permits.) 

2. Discharges from Concentrated Aquatic Animal Production 

Facilities. (See Glossary for size cutoffs.) 

3. Discharges associated with approved Aquaculture Projects. 

4. Discharges from Silvicultural Point Sources. (See Glossary 

for the definition of “silvicultural point source.”) Nonpoint source 

silvicultural activities are excluded from NPDES permit requirements. However, some of these activities, such as stream 

crossings for roads, may involve point source discharges of 

dredged or fill material which may require a Section 404 permit. 

See 33 CFR 209.120. 

E. DISCHARGES IN COMPLIANCE WITH AN ON-SCENE COORDINATOR'S INSTRUCTIONS. 

II. Hazardous Waste Permits Under the Resource Conservation 

and Recovery Act. You may be excluded from the requirement to 

obtain a permit under this program if you fall into one of the following 

categories: 

Generators who accumulate their own hazardous waste on-site for 

less than 90 days as provided in 40 CFR 262.34; 

Farmers who dispose of hazardous waste pesticide from their own 

use as provided in 40 CFR 262.51; 

Certain persons treating, storing, or disposing of small quantities 

of hazardous waste as provided in 40 CFR 261.4 or 261.5; and 

Owners and operators of totally enclosed treatment facilities as 

defined in 40 CFR 260.10. 

Check with your Regional office for details. Please note that even if 

you are excluded from permit requirements, you may be required by 

Federal regulations to handle your waste in a particular manner. 

III. Underground Injection Control Permits Under the Safe Drinking Water Act. You are not required to obtain a permit under this 

program if you: 

Inject into existing wells used to enhance recovery of oil and gas 

or to store hydrocarbons (note, however, that these underground 

injections are regulated by Federal rules); or 

Inject into or above a stratum which contains, within 1/4 mile of the 

well bore, an underground source of drinking water (unless your 

injection is the type identified in Item II-H, for which you do need a 

permit). However, you must notify EPA of your injection and submit certain required information on forms supplied by the Agency, 

and your operation may be phased out if you are a generator of 

hazardous wastes or a hazardous waste management facility 

which uses wells or septic tanks to dispose of hazardous waste. 

IV. Prevention of Significant Deterioration Permits Under the 

Clean Air Act. The PSD program applies to newly constructed or 

modified facilities (both of which are referred to as “new sources”) 

which increase air emissions. The Clean Air Act Amendments of 

1977 exclude small new sources of air emissions from the PSD 

review program. Any new source in an industrial category listed in 

Table 3 of these instructions whose potential to emit is less than 100 

tons per year is not required to get a PSD permit. In addition, any 

new source in an industrial category not listed in Table 3 whose 

potential to emit is less than 250 tons per year is exempted from the 

PSD requirements. 

Modified sources which increase their net emissions (the difference 

between the total emission increases and total emission decreases 

at the source) less than the significant amount set forth in EPA 

regulations are also exempt from PSD requirements. Contact your 

EPA Regional office (Table 1) for further information. 
SECTION D – GLOSSARY 

1-6

NOTE: This Glossary includes terms used in the instructions and in Forms 1, 2B, 2C, and 3. Additional terms will be included in the future when 

other forms are developed to reflect the requirements of other parts of the Consolidated Permits Program. If you have any questions concerning the 

meaning of any of these terms, please contact your EPA Regional office (Table 1) 

.

ALIQUOT means a sample of specified volume used to make up a 

total composite sample. 

ANIMAL FEEDING OPERATION means a lot or facility (other than 

an aquatic animal production facility) where the following conditions 

are met; 

A. 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 

B. Crops, vegetation, forage growth, or post-harvest residues are 

not sustained in the normal growing season over any portion of 

the lot or facility. 

Two or more animal feeding operations under common ownership 

are a single animal feeding operation if they adjoin each other or if 

they use a common area or system for the disposal of wastes. 

ANIMAL UNIT means a unit of measurement for any animal feeding 

operation calculated by adding the following numbers: The number 

of slaughter and feeder cattle multiplied by 1.0; Plus the number of 

mature dairy cattle multiplied by 1.4; Plus the number of swine 

weighing over 25 kilograms (approximately 55 pounds) multiplied by 

0.4; Plus the number of sheep multiplied by 0.1; Plus the number of 

horses multiplied by 2.0. 

APPLICATION means the EPA standard national forms for applying 

for a permit, including any additions, revisions, or modifications to the 

forms; or forms approved by EPA for use in approved States, including any approved modifications or revisions. For RCRA, “application” 

also means “Application, Part B.” 

APPLICATION, PART A means that part of the Consolidated Permit 

Application forms which a RCRA permit applicant must complete to 

qualify for interim status under Section 3005(e) of RCRA and for 

consideration for a permit. Part A consists of Form 1 (General Information) and Form 3 (Hazardous Waste Application Form). 

APPLICATION, PART B means that part of the application which a 

RCRA permit applicant must complete to be issued a permit. (NOTE: 

EPA is not developing a specific form for Part B of the permit application, but an instruction booklet explaining what Information must 

be supplied is available from the EPA Regional office.) 

APPROVED PROGRAM or APPROVED STATE means a State 

program which has been approved or authorized by EPA under 40 

CFR Part 123. 

AQUACULTURE PROJECT means a defined managed water area 

which uses discharges of pollutants into that designated area for the 

maintenance or production of harvestable freshwater, estuarine, or 

marine plants or animals. “Designated area” means the portions of 

the waters of the United States within which the applicant plans to 

confine the cultivated species, using a method of plan or operation 

(including, but not limited to, physical confinement) which, on the 

basis of reliable scientific evidence, is expected to ensure the specific individual organisms comprising an aquaculture crop will enjoy 

increased growth attributable to the discharge of pollutants and be 

harvested within a defined geographic area. 

AQUIFER means a geological formation, group of formations, or part 

of a formation that is capable of yielding a significant amount of 

water to a well or spring. 

AREA OF REVIEW means the area surrounding an injection which is 

described according to the criteria set forth in 40 CFR Section 

146.06. 

AREA PERMIT means a UIC permit applicable to all or certain wells 

within a geographic area, rather than to a specified well, under 40 

CFR Section 122.37. 

ATTAINMENT AREA means, for any air pollutant, an area which has 

been designated under Section 107 of the Clean Air Act as having 

ambient air quality levels better than any national primary or secondary ambient air quality standard for that pollutant. Standards have 

been set for sulfur oxides, particulate matter, nitrogen dioxide, carbon monoxide, ozone, lead, and hydrocarbons. For purposes of the 

Glossary, “attainment area” also refers to “unclassifiable area,” which 

means, for any pollutants, an area designated under Section 107 as 

unclassifiable with respect to that pollutant due to insufficient Information. 

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. BMP’s include treatment requirements, 

operation procedures, and practices to control plant site runoff, 

spillage or leaks, sludge or waste disposal, or drainage from raw 

material storage. 

BIOLOGICAL MONITORING TEST means any test which includes 

the use of aquatic algal, invertebrate, or vertebrate species to measure acute or chronic toxicity, and any biological or chemical measure 

of bioaccumulation. 

BYPASS means the intentional diversion of wastes from any portion 

of a treatment facility. 

CONCENTRATED ANIMAL FEEDING OPERATION means an 

animal feeding operation which meets the criteria set forth in either 

(A) or (B) below or which the Director 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), 

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 facility 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 
SECTION D – GLOSSARY 

1-7

Either one of the following conditions are met: Pollutants are 

discharged into waters of the United States through a manmade 

ditch, 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, across, 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 concentrated animal feeding operation as defined above if such 

animal feeding operation discharges only in the event of a 25 

year, 24 hour storm event. 

CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY 

means a hatchery, fish farm, or other facility which contains, grows 

or holds aquatic animals in either of the following categories, or 

which the Director designates as such on a case-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 kilograms (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 during 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. 

CONTACT COOLING WATER means water used to reduce temperature which comes into contact with a raw material, intermediate 

product, waste product other than heat, or finished product. 

CONTAINER means any portable device in which a material is 

stored, transported, treated, disposed of, or otherwise handled. 

CONTIGUOUS ZONE means the entire zone established by the 

United States under article 24 of the convention of the Territorial Sea 

and the Contiguous Zone. 

CWA means the Clean Water Act (formerly referred to the Federal 

Water Pollution Control Act) Pub. L. 92-500, as amended by Pub. L. 

95-217 and Pub. L. 95-576, 33 U.S.C. 1251 et seq. 

DIKE means any embankment or ridge of either natural or manmade 

materials used to prevent the movement of liquids, sludges, solids, 

or other materials. 

DIRECT DISCHARGE means the discharge of a pollutant as defined 

below. 

DIRECTOR means the EPA Regional Administrator or the State 

Director as the context requires. 

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 the 

waters of the contiguous zone or the ocean from any point source 

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 States 

from: Surface runoff which is collected or channelled by man; Discharges through pipes, sewers, or other conveyances owned by a 

State, municipality, or other person which do not lead to POTW’s; 

and Discharges through pipes, sewers, or other conveyances, leading into privately owned treatment works. This term does not include 

an addition of pollutants by any indirect discharger. 

DISPOSAL (in the RCRA program) means the discharge, deposit, 

injection, dumping, spilling, leaking, or placing of any hazardous 

waste into or on any land or water so that the hazardous waste or 

any constituent of it may enter the environment or be emitted into the 

air or discharged into any waters, including ground water. 

DISPOSAL FACILITY means a facility or part of a facility at which 

hazardous waste is intentionally placed into or on land or water, and 

at which hazardous waste will remain after closure. 

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 continguous zone, or the ocean. 

EFFLUENT LIMITATION GUIDELINE means a regulation published 

by the Administrator under Section 304(b) of the Clean Water Act to 

adopt or revise effluent limitations. 

ENVIRONMENTAL PROTECTION AGENCY (EPA) means the 

United States Environmental Protection Agency. 

EPA IDENTIFICATION NUMBER means the number assigned by 

EPA to each generator, transporter, and facility. 

EXEMPTED AQUIFER means an aquifer or its portion that meets 

the criteria in the definition of USDW, but which has been exempted 

according to the procedures in 40 CFR Section 122.35(b). 

EXISTING HWM FACILITY means a Hazardous Waste Management 

facility which was in operation, or for which construction had commenced, on or before October 21, 1976. Construction had commenced if (A) the owner or operator had obtained all necessary 

Federal, State, and local preconstruction approvals or permits, and 

either (B1) a continuous on-site, physical construction program had 

begun, or (B2) the owner or operator had entered into contractual 

obligations, which could not be cancelled or modified without substantial loss, for construction of the facility to be completed within a 

reasonable time. 

(NOTE: This definition reflects the literal language of the statute. 

However, EPA believes that amendments to RCRA now in conference will shortly be enacted and will change the date for determining when a facility is an “existing facility” to one no earlier than 

May of 1980; indications are the conferees are considering October 30, 1980. Accordingly, EPA encourages every owner or operator of a facility which was built or under construction as of the 

promulgation date of the RCRA program regulations to file Part A 

of its permit application so that it can be quickly processed for interim status when the change in the law takes effect. When those 

amendments are enacted, EPA will amend this definition.) 

EXISTING SOURCE or EXISTING DISCHARGER (in the NPDES 

program) means any source which is not a new source or a new 

discharger. 

EXISTING INJECTION WELL means an injection well other than a 

new injection well. 

FACILITY means any HWM facility, UIC underground injection well, 

NPDES point source, PSD stationary source, or any other facility or 

activity (including land or appurtenances thereto) that is subject to 

regulation under the RCRA, UIC, NPDES, or PSD programs. 

FLUID means material or substance which flows or moves whether 

in a semisolid, liquid, sludge, gas, or any other form or state. 

GENERATOR means any person by site, whose act or process 

produces hazardous waste identified or listed in 40 CFR Part 261. 

GROUNDWATER means water below the land surface in a zone of 

saturation. 

HAZARDOUS SUBSTANCE means any of the substances designated under 40 CFR Part 116 pursuant to Section 311 of CWA. 

(NOTE: These substances are listed in Table 2c-4 of the instructions 

to Form 2C.) 
SECTION D – GLOSSARY 

1-8

HAZARDOUS WASTE means a hazardous waste as defined in 40 

CFR Section 261.3 published May 19, 1980. 

HAZARDOUS WASTE MANAGEMENT FACILITY (HWM facility)

means all contiguous land, structures, appurtenances, and improvements on the land, used for treating, storing, or disposing of hazardous wastes. A facility may consist of several treatment, storage, or 

disposal operational units (for example, one or more landfills, surface 

impoundments, or combinations of them). 

IN OPERATION means a facility which is treating, storing, or disposing of hazardous waste. 

INCINERATOR (in the RCRA program) means an enclosed device 

using controlled flame combustion, the primary purpose of which is 

to thermally break down hazardous waste. Examples of incinerators 

are rotary kiln, fluidized bed, and liquid injection incinerators. 

INDIRECT DISCHARGER means a nondomestic discharger introducing pollutants to a publicly owned treatment works. 

INJECTION WELL means a well into which fluids are being injected. 

INTERIM AUTHORIZATION means approval by EPA of a State 

hazardous waste program which has met the requirements of Section 3006(c) of RCRA and applicable requirements of 40 CFR Part 

123, Subparts A, B, and F. 

LANDFILL means a disposal facility or part of a facility where hazardous waste is placed in or on land and which is not a land treatment facility, a surface impoundment, or an injection well. 

LAND TREATMENT FACILITY (in the RCRA program) means a 

facility or part of a facility at which hazardous waste is applied onto 

or incorporated into the soil surface; such facilities are disposal 

facilities if the waste will remain after closure. 

LISTED STATE means a State listed by the Administrator under 

Section 1422 of SDWA as needing a State UIC program. 

MGD means millions of gallons per day. 

MUNICIPALITY means a city, village, town, borough, county, parish, 

district, association, 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 

tribal organization, or a designated and approved management 

agency under Section 208 of CWA. 

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 Sections 

307, 318, 402, 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 new or additional discharge of pollutants at a site at which on October 18, 1972, it had 

never discharged pollutants; (B) Which has never received a finally 

effective NPDES permit for discharges at that site; and (C) Which is 

not a “new source.” This definition includes an indirect discharger 

which commences discharging into waters of the United States. It 

also includes any existing mobile point source, such as an offshore 

oil drilling rig, seafood processing vessel, or aggregate plant that 

begins discharging at a location for which it does not have an existing permit. 

NEW HWM FACILITY means a Hazardous Waste Management 

facility which began operation or for which construction commenced 

after October 21, 1976. 

NEW INJECTION WELL means a well which begins injection after a 

UIC program for the State in which the well is located is approved. 

NEW SOURCE (in the NPDES program) 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 Section 

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 only 

if the standards are promulgated in accordance with Section 306 

within 120 days of their proposal. 

NON-CONTACT COOLING WATER means water used to reduce 

temperature which does not come into direct contact with any raw 

material, intermediate product, waste product (other than heat), or 

finished product. 

OFF-SITE means any site which is not “on-site”. 

ON-SITE means on the same or geographically contiguous property 

which may be divided by public or private right(s)-of-way, provided 

the entrance and exit between the properties is at a cross-roads 

intersection, and access is by crossing as opposed to going along, 

the right(s)-of-way. Non-contiguous properties owned by the same 

person, but connected by a right-of-way which the person controls 

and to which the public does not have access, is also considered 

on-site property. 

OPEN BURNING means the combustion of any material without the 

following characteristics; 

A. Control of combustion air to maintain adequate temperature for 

efficient combustion; 

B. Containment of the combustion-reaction in an enclosed device 

to provide sufficient residence time and mixing for complete combustion; and 

C. Control of emission of the gaseous combustion products. 

(See also “incinerator” and “thermal treatment”). 

OPERATOR means the person responsible for the overall operation 

of a facility. 

OUTFALL means a point source. 

OWNER means the person who owns a facility or part of a facility. 

PERMIT means an authorization, license, or equivalent control 

document issued by EPA or an approved State to implement the 

requirements of 40 CFR Parts 122, 123, and 124. 

PHYSICAL CONSTRUCTION (in the RCRA program) means excavation, movement of earth, erection of forms or structures, or similar 

activity to prepare a HWM facility to accept hazardous waste. 

PILE means any noncontainerized accumulation of solid, nonflowing 

hazardous waste that is used for treatment or storage. 

POINT SOURCE means any discernible, confined, and discrete 

conveyance, including but not limited to any pipe, ditch, channel, 

tunnel, conduit, well, discrete fissure, container, rolling stock, concentrated animal feeding operation, vessel or other floating craft from 

which pollutants are or may be discharged. This term does not include return flows from irrigated agriculture. 

POLLUTANT means dredged spoil, solid waste, incinerator residue, 

filter backwash, sewage, garbage, sewage sludge, munitions, 

chemical waste, biological materials, radioactive materials (except 

those regulated under the Atomic Energy Act of 1954, as amended 

[42 U.S.C. Section 2011 et seq.]), heat, wrecked or discarded 

equipment, rocks, sand, cellar dirt and Industrial, municipal, and 

agriculture waste discharged into water. It does not mean: 

A. Sewage from vessels; or 

B. Water, gas, or other material which is injected into a well to facilitate production of oil or gas, or water derived in association 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 

degradation of ground or surface water resources. 

(NOTE: Radioactive materials covered by the Atomic Energy Act 

are those encompassed in its definition of source, byproduct, or 

special nuclear materials. Examples of materials not covered include radium and accelerator produced isotopes. See Train v. 

Colorado Public Interest Research Group, Inc., 426 U.S. 1 [1976].) 
SECTION D – GLOSSARY 

1-9

PREVENTION OF SIGNIFICANT DETERIORATION (PSD) means 

the national permitting program under 40 CFR 52.21 to prevent 

emissions of certain pollutants regulated under the Clean Air Act 

from significantly deteriorating air quality in attainment areas. 

PRIMARY INDUSTRY CATEGORY means any industry category 

listed in the NRDC Settlement Agreement (Natural Resources Defense Council v. Train, 8 ERC 2120 [D.D.C. 1976], modified 12 ERC 

1833 [D.D.C. 1979]).

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, intermediate product, 

finished product, byproduct, or waste product. 

PUBLICLY OWNED TREATMENT WORKS or POTW means any 

device or system used in the treatment (including recycling and 

reclamation) of municipal sewage or industrial wastes of a liquid 

nature which is owned by a State or municipality. This definition 

includes any sewers, pipes, or other conveyances only if they convey 

wastewater to a POTW providing treatment. 

RENT means use of another’s property in return for regular payment. 

RCRA means the Solid Waste Disposal Act as amended by the 

Resource Conservation and Recovery Act of 1976 (Pub. L. 94-580, 

as amended by Pub. L. 95-609, 42 U.S.C. Section 6901 at seq.). 

ROCK CRUSHING AND GRAVEL WASHING FACILITIES are facilities which process crushed and broken stone, gravel, and riprap (see 

40 CFR Part 436, Subpart B, and the effluent limitations guidelines 

for these facilities). 

SDWA means the Safe Drinking Water Act (Pub. L 95-523, as 

amended by Pub. L. 95-1900, 42 U.S.C. Section 300[f] et seq.). 

SECONDARY INDUSTRY 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 

vessels on the Great Lakes this term includes graywater. For the 

purposes of this definition, “graywater” means galley, bath, and 

shower water, 

SEWAGE SLUDGE means the solids, residues, and precipitate 

separated from or created in sewage by the unit processes of a 

POTW. “Sewage” as used in this definition means any wastes, 

including wastes from humans, households, commercial establishments, industries, and storm water runoff, that are discharged to or 

otherwise enter a publicly owned treatment works. 

SlLVICULTURAL POINT SOURCE means any discernable, confined, and discrete conveyance related to rock crushing, gravel 

washing, log sorting, or log storage facilities 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 fire control, harvesting 

operations, surface drainage, or road construction and maintenance 

from which there is natural runoff. However, some of these activities 

(such as stream crossing for roads) may involve point source discharges of dredged or fill material which may require a CWA Section 

404 permit. “Log sorting and log storage facilities” are facilities 

whose discharges result from the holding of unprocessed wood, e.g., 

logs or roundwood with bark or after removal of bark in 

self-contained bodies of water (mill ponds or log ponds) or stored on 

land where water is applied intentionally on the logs (wet decking). 

(See 40 CFR Part 429, Subpart J, and the effluent limitations guidelines for these facilities.) 

STATE means any of the 50 States, the District of Columbia, Guam, 

the Commonwealth of Puerto Rico, the Virgin Islands, American 

Samoa, the Trust Territory of the Pacific Islands (except in the case 

of RCRA), and the Commonwealth of the Northern Mariana Islands 

(except in the case of CWA). 

STATIONARY SOURCE (in the PSD program) means any building, 

structure, facility, or installation which emits or may emit any air 

pollutant regulated under the Clean Air Act. “Building, structure, 

facility, or installation” means any grouping of pollutant-emitting 

activities which are located on one or more contiguous or adjacent 

properties and which are owned or operated by the same person (or 

by persons under common control). 

STORAGE (in the RCRA program) means the holding of hazardous 

waste for a temporary period at the end of which the hazardous 

waste is treated, disposed, or stored elsewhere. 

STORM WATER RUNOFF means water discharged as a result of 

rain, snow, or other precipitation. 

SURFACE IMPOUNDMENT or IMPOUNDMENT means a facility or 

part of a facility which is a natural topographic depression, manmade 

excavation, or diked area formed primarily of earthen materials 

(although it may be lined with manmade materials), which is designed to hold an accumulation of liquid wastes or wastes containing 

free liquids, and which is not an injection well. Examples of surface 

impoundments are holding, storage, settling, and aeration pits, 

ponds, and lagoons. 

TANK (in the RCRA program) means a stationary device, designed 

to contain an accumulation of hazardous waste which is constructed 

primarily of non-earthen materials (e.g., wood, concrete, steel, plastic) which provide structural support. 

THERMAL TREATMENT (in the RCRA program) means the treatment of hazardous waste in a device which uses elevated temperature as the primary means to change the chemical, physical, or 

biological character or composition of the hazardous waste. Examples of thermal treatment processes are incineration, molten salt, 

pyrolysis, calcination, wet air oxidation, and microwave discharge. 

(See also “incinerator” and “open burning”). 

TOTALLY ENCLOSED TREATMENT FACILITY (in the RCRA program) means a facility for the treatment of hazardous waste which is 

directly connected to an industrial production process and which is 

constructed and operated in a manner which prevents the release of 

any hazardous waste or any constituent thereof into the environment 

during treatment. An example is a pipe in which waste acid is neutralized. 

TOXIC POLLUTANT means any pollutant listed as toxic under Section 307(a)(1) of CWA. 

TRANSPORTER (in the RCRA program) means a person engaged 

in the off-site transportation of hazardous waste by air, rail, highway, 

or water. 

TREATMENT (in the RCRA program) means any method, technique, 

or process, including neutralization, designed to change the physical, 

chemical, or biological character or composition of any hazardous 

waste so as to neutralize such waste, or so as to recover energy or 

material resources from the waste, or so as to render such waste 

non-hazardous, or less hazardous; safer to transport, store, or dispose of; or amenable for recovery, amenable for storage, or reduced 

in volume. 

UNDERGROUND INJECTION means well injection. 

UNDERGROUND SOURCE OF DRINKING WATER or USDW 

means an aquifer or its portion which is not an exempted aquifer 

and: 

A. Which supplies drinking water for human consumption; or 

B. In which the ground water contains fewer than 10,000 mg/l total 

dissolved solids. 

UPSET means an exceptional incident in which there is unintentional 

and temporary noncompliance with technology-based permit effluent 

limitations because of factors beyond the reasonable control of the 

permittee. An upset does not include noncompliance to the extent 

caused by operational error, improperly designed treatment facilities, 

inadequate treatment facilities, lack of preventive maintenance, or 

careless or improper operation. 
SECTION D – GLOSSARY 

1-10

WATERS OF THE UNITED STATES 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, streams (including intermittent streams), mudflats, sandflats, wetlands, 

sloughs, prairie potholes, wet meadows, playa lakes, and natural 

ponds, the use, degradation, or destruction of which would or 

could affect interstate or foreign commerce including any such waters; 

1. Which are or could be used by interstate or foreign travelers 

for recreational or other purposes, 

2. From which fish or shellfish are or could be taken and sold in 

interstate or foreign commerce, 

3. Which are used or could be used for industrial purposes by 

industries in interstate commerce; 

D. All impoundments of waters otherwise defined as waters of the 

United States under this definition; 

E. Tributaries of waters identified in paragraphs (A) – (D) above; 

F. The territorial sea; and 

G. Wetlands adjacent to waters (other than waters that are themselves wetlands) identified in paragraphs (A) – (F) of this definition. 

Waste treatment systems, including treatment ponds or lagoons 

designed to meet requirement of CWA (other than cooling ponds as 

defined In 40 CFR Section 423.11(m) which also meet the criteria of 

this definition) are not waters of the United States. This exclusion 

applies only to manmade bodies of water which neither were originally created in waters of the United States (such as a disposal area 

in wetlands) nor resulted from the impoundments of waters of the 

United States. 

WELL INJECTION or UNDERGROUND INJECTION means the 

subsurface emplacement of fluids through a bored, drilled, or driven 

well; or through a dug well, where the depth of the dug well is greater 

than the largest surface dimension. 

WETLANDS means those areas that are inundated or saturated by 

surface or groundwater at a frequency and duration sufficient to 

support, and that under normal circumstances do support, a prevalence of vegetation typically adapted for life in saturated soil conditions. Wetlands generally include swamps, marshes, bogs, and 

similar areas. 

Please print or type in the unshaded areas only. Form Approved. OMB No. 2040-0086. 

I. EPA I.D. NUMBER 

S T/A C 

F D 

FORM 

1 

GENERAL 

U.S. ENVIRONMENTAL PROTECTION AGENCY 

GENERAL INFORMATION 

Consolidated Permits Program 

(Read the “General Instructions” before starting.) 1 2 13 14 15

LABEL ITEMS 

I. EPA I.D. NUMBER 

III. FACILITY NAME 

V. FACILITY MAILING 

ADDRESS 

VI. FACILITY LOCATION 

PLEASE PLACE LABEL IN THIS SPACE 

GENERAL INSTRUCTIONS 

If a preprinted label has been provided, affix it in the 

designated space. Review the information carefully; if any of it 

is incorrect, cross through it and enter the correct data in the 

appropriate fill-in area below. Also, if any of the preprinted data 

is absent (the area to the left of the label space lists the 

information that should appear), please provide it in the proper 

fill-in area(s) below. If the label is complete and correct, you 

need not complete Items I, III, V, and VI (except VI-B which 

must be completed regardless). Complete all items if no label 

has been provided. Refer to the instructions for detailed item 

descriptions and for the legal authorizations under which this 

data is collected.

II. POLLUTANT CHARACTERISTICS 

INSTRUCTIONS: Complete A through J to determine whether you need to submit any permit application forms to the EPA. If you answer “yes” to any questions, you must 

submit this form and the supplemental form listed in the parenthesis following the question. Mark “X” in the box in the third column if the supplemental form is attached. If 

you answer “no” to each question, you need not submit any of these forms. You may answer “no” if your activity is excluded from permit requirements; see Section C of the 

instructions. See also, Section D of the instructions for definitions of bold-faced terms. 

Mark “X” Mark “X” 

SPECIFIC QUESTIONS YES NO FORM 

ATTACHED SPECIFIC QUESTIONS YES NO FORM ATTACHED 

A. Is this facility a publicly owned treatment works which 

results in a discharge to waters of the U.S.? (FORM 2A) 

16 17 18 

B. Does or will this facility (either existing or proposed)

include a concentrated animal feeding operation or 

aquatic animal production facility which results in a 

discharge to waters of the U.S.? (FORM 2B) 19 20 21 

C. Is this a facility which currently results in discharges to 

waters of the U.S. other than those described in A or B 

above? (FORM 2C) 22 23 24

D. Is this a proposed facility (other than those described in A 

or B above) which will result in a discharge to waters of 

the U.S.? (FORM 2D) 25 26 27

E. Does or will this facility treat, store, or dispose of 

hazardous wastes? (FORM 3) 

28 29 30

F. Do you or will you inject at this facility industrial or 

municipal effluent below the lowermost stratum 

containing, within one quarter mile of the well bore, 

underground sources of drinking water? (FORM 4) 31 32 33

G. Do you or will you inject at this facility any produced water 

or other fluids which are brought to the surface in 

connection with conventional oil or natural gas production, 

inject fluids used for enhanced recovery of oil or natural 

gas, or inject fluids for storage of liquid hydrocarbons? 

(FORM 4) 34 35 36 

H. Do you or will you inject at this facility fluids for special 

processes such as mining of sulfur by the Frasch process, 

solution mining of minerals, in situ combustion of fossil 

fuel, or recovery of geothermal energy? (FORM 4) 

37 38 39 

I. Is this facility a proposed stationary source which is one 

of the 28 industrial categories listed in the instructions and 

which will potentially emit 100 tons per year of any air 

pollutant regulated under the Clean Air Act and may affect 

or be located in an attainment area? (FORM 5) 40 41 42 

J. Is this facility a proposed stationary source which is 

NOT one of the 28 industrial categories listed in the 

instructions and which will potentially emit 250 tons per 

year of any air pollutant regulated under the Clean Air Act 

and may affect or be located in an attainment area? 

(FORM 5) 

43 44 45 

III. NAME OF FACILITY 

C 

1 SKIP 

15 16 – 29 30 69 

IV. FACILITY CONTACT 

A. NAME & TITLE (last, first, & title) B. PHONE (area code & no.) 

C 

2 

15 16 45 46 48 49 51 52- 55 

V. FACILTY MAILING ADDRESS 

A. STREET OR P.O. BOX 

C 

3 

15 16 45 

B. CITY OR TOWN C. STATE D. ZIP CODE 

C 

4 

15 16 40 41 42 47 51 

VI. FACILITY LOCATION 

A. STREET, ROUTE NO. OR OTHER SPECIFIC IDENTIFIER 

C 

5 

15 16 45 

B. COUNTY NAME 

 

 

46 70 

C. CITY OR TOWN D. STATE E. ZIP CODE F. COUNTY CODE (if known)

C 

6 

15 16 40 41 42 47 51 52 -54 

EPA Form 3510-1 (8-90) CONTINUE ON REVERSE 
CONTINUED FROM THE FRONT 

VII. SIC CODES (4-digit, in order of priority) 

A. FIRST B. SECOND C C 

7 7 

15 16 - 19 

(specify)

15 16 - 19

(specify) 

C. THIRD D. FOURTH C C 

7 7 

15 16 - 19 

(specify)

15 16 - 19

(specify)

VIII. OPERATOR INFORMATION 

A. NAME C 

8 

15 16 55

B. Is the name listed in Item 

VIII-A also the owner? 

 YES  NO 66 

C. STATUS OF OPERATOR (Enter the appropriate letter into the answer box: if “Other,” specify.) D. PHONE (area code & no.) 

c 

A F = FEDERAL 

S = STATE 

P = PRIVATE 

M = PUBLIC (other than federal or state) 

O = OTHER (specify) 

56 

(specify) 

15 6 - 18 19 - 21 22 - 26 

E. STREET OR P.O. BOX 

 

26 55

F. CITY OR TOWN G. STATE H. ZIP CODE IX. INDIAN LAND C 

B 

15 16 40 41 42 47 - 51 

Is the facility located on Indian lands? 

 YES  NO 52 

X. EXISTING ENVIRONMENTAL PERMITS 

A. NPDES (Discharges to Surface Water) D. PSD (Air Emissions from Proposed Sources) 

C T I C T I 

9 N 9 P 

15 16 17 18 30 15 16 17 18 30 

B. UIC (Underground Injection of Fluids) E. OTHER (specify) 

C T I C T I 

9 U 9 

15 16 17 18 30 15 16 17 18 30 

(specify) 

C. RCRA (Hazardous Wastes) E. OTHER (specify)

C T I C T I 

9 R 9 (specify)

15 16 17 18 30 15 16 17 18 30 

XI. MAP 

Attach to this application a topographic map of the area extending to at least one mile beyond property boundaries. The map must show the outline of the facility, the 

location of each of its existing and proposed intake and discharge structures, each of its hazardous waste treatment, storage, or disposal facilities, and each well where it 

injects fluids underground. Include all springs, rivers, and other surface water bodies in the map area. See instructions for precise requirements. 

XII. NATURE OF BUSINESS (provide a brief description) 

XIII. CERTIFICATION (see instructions) 

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attachments and that, based on my 

inquiry of those persons immediately responsible for obtaining the information contained in the application, I believe that the information is true, accurate, and complete. I 

am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. 

A. NAME & OFFICIAL TITLE (type or print) B. SIGNATURE C. DATE SIGNED 

COMMENTS FOR OFFICIAL USE ONLY 

C 

C 

15 16 55 

EPA Form 3510-1 (8-90) 
Disclaimer 

This is an updated PDF document that allows you to type your information 

directly into the form, print it, and save the completed form. 

Note: This form can be viewed and saved only using Adobe Acrobat Reader 

version 7.0 or higher, or if you have the full Adobe Professional version. 

Instructions: 

1. Type in your information 

2. Save file (if desired) 

3. Print the completed form 

4. Sign and date the printed copy 

5. Mail it to the directed contact. 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 1 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

FORM

2A 

NPDES

NPDES FORM 2A APPLICATION OVERVIEW 

APPLICATION OVERVIEW 

Form 2A has been developed in a modular format and consists of a "Basic Application Information" packet and 

a "Supplemental Application Information" packet. The Basic Application Information packet is divided into two 

parts. All applicants must complete Parts A and C. Applicants with a design flow greater than or equal to 0.1 

mgd must also complete Part B. Some applicants must also complete the Supplemental Application 

Information packet. The following items explain which parts of Form 2A you must complete. 

BASIC APPLICATION INFORMATION: 

A. Basic Application Information for all Applicants. All applicants must complete questions A.1 through A.8. A treatment 

works that discharges effluent to surface waters of the United States must also answer questions A.9 through A.12. 

B. Additional Application Information for Applicants with a Design Flow > 0.1 mgd. All treatment works that have design 

flows greater than or equal to 0.1 million gallons per day must complete questions B.1 through B.6. 

C. Certification. All applicants must complete Part C (Certification). 

SUPPLEMENTAL APPLICATION INFORMATION: 

D. Expanded Effluent Testing Data. A treatment works that discharges effluent to surface waters of the United States and 

meets one or more of the following criteria must complete Part D (Expanded Effluent Testing Data): 

1. Has a design flow rate greater than or equal to 1 mgd, 

2. Is required to have a pretreatment program (or has one in place), or 

3. Is otherwise required by the permitting authority to provide the information. 

E. Toxicity Testing Data. A treatment works that meets one or more of the following criteria must complete Part E (Toxicity 

Testing Data): 

1. Has a design flow rate greater than or equal to 1 mgd, 

2. Is required to have a pretreatment program (or has one in place), or 

3. Is otherwise required by the permitting authority to submit results of toxicity testing. 

F. Industrial User Discharges and RCRA/CERCLA Wastes. A treatment works that accepts process wastewater from any 

significant industrial users (SIUs) or receives RCRA or CERCLA wastes must complete Part F (Industrial User Discharges and 

RCRA/CERCLA Wastes). SIUs are defined as: 

1. All industrial users subject to Categorical Pretreatment Standards under 40 Code of Federal Regulations (CFR) 403.6 and 

40 CFR Chapter I, Subchapter N (see instructions); and 

2. Any other industrial user that: 

a. Discharges an average of 25,000 gallons per day 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.

G. Combined Sewer Systems. A treatment works that has a combined sewer system must complete Part G (Combined Sewer 

Systems). 

ALL APPLICANTS MUST COMPLETE PART C (CERTIFICATION) 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 2 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

BASIC APPLICATION INFORMATION 

PART A. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS: 

All treatment works must complete questions A.1 through A.8 of this Basic Application Information packet. 

A.1. Facility Information. 

Facility name 

Mailing Address 

 

Contact person 

Title 

Telephone number 

Facility Address 

(not P.O. Box) 

A.2. Applicant Information. If the applicant is different from the above, provide the following:

Applicant name 

Mailing Address 

 

Contact person 

Title 

Telephone number 

Is the applicant the owner or operator (or both) of the treatment works?

 owner operator 

Indicate whether correspondence regarding this permit should be directed to the facility or the applicant. 

 facility applicant 

A.3. Existing Environmental Permits. Provide the permit number of any existing environmental permits that have been issued to the treatment 

works (include state-issued permits).

 NPDES PSD 

 UIC Other 

 RCRA Other 

A.4. Collection System Information. Provide information on municipalities and areas served by the facility. Provide the name and population of 

each entity and, if known, provide information on the type of collection system (combined vs. separate) and its ownership (municipal, private, 

etc.).

Name Population Served Type of Collection System Ownership 

 

 

 

Total population served

 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 3 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

A.5. Indian Country. 

a. Is the treatment works located in Indian Country? 

 Yes No 

b. Does the treatment works discharge to a receiving water that is either in Indian Country or that is upstream from (and eventually flows 

through) Indian Country? 

 Yes No 

A.6. Flow. Indicate the design flow rate of the treatment plant (i.e., the wastewater flow rate that the plant was built to handle). Also provide the 

average daily flow rate and maximum daily flow rate for each of the last three years. Each year's data must be based on a 12-month time 

period with the 12th month of "this year" occurring no more than three months prior to this application submittal. 

a. Design flow rate _______________ mgd 

 Two Years Ago Last Year This Year 

b. Annual average daily flow rate mgd 

c. Maximum daily flow rate mgd 

A.7. Collection System. Indicate the type(s) of collection system(s) used by the treatment plant. Check all that apply. Also estimate the percent 

contribution (by miles) of each. 

 Separate sanitary sewer % 

 Combined storm and sanitary sewer % 

A.8. Discharges and Other Disposal Methods.

a. Does the treatment works discharge effluent to waters of the U.S.? Yes No 

 If yes, list how many of each of the following types of discharge points the treatment works uses: 

i. Discharges of treated effluent 

ii. Discharges of untreated or partially treated effluent 

iii. Combined sewer overflow points 

iv. Constructed emergency overflows (prior to the headworks) 

v. Other 

b. Does the treatment works discharge effluent to basins, ponds, or other surface 

impoundments that do not have outlets for discharge to waters of the U.S.? Yes 

 

No 

If yes, provide the following for each surface impoundment: 

Location: 

Annual average daily volume discharged to surface impoundment(s) mgd

Is discharge continuous or intermittent? 

c. Does the treatment works land-apply treated wastewater? Yes No 

If yes, provide the following for each land application site: 

Location: 

Number of acres: 

Annual average daily volume applied to site: Mgd

Is land application continuous or intermittent? 

d. Does the treatment works discharge or transport treated or untreated wastewater to another 

treatment works? 

 

Yes 

 

No 

 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 4 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

 If yes, describe the mean(s) by which the wastewater from the treatment works is discharged or transported to the other treatment 

works (e.g., tank truck, pipe). 

If transport is by a party other than the applicant, provide: 

Transporter name: 

Mailing Address: 

 

Contact person: 

Title: 

Telephone number: 

For each treatment works that receives this discharge, provide the following: 

Name: 

Mailing Address: 

 

Contact person: 

Title: 

Telephone number: 

If known, provide the NPDES permit number of the treatment works that receives this discharge. 

Provide the average daily flow rate from the treatment works into the receiving facility. mgd 

e. Does the treatment works discharge or dispose of its wastewater in a manner not included in 

A.8.a through A.8.d above (e.g., underground percolation, well injection)? Yes 

 

No 

If yes, provide the following for each disposal method: 

Description of method (including location and size of site(s) if applicable): 

Annual daily volume disposed of by this method: 

Is disposal through this method continuous or intermittent? 

 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 5 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

WASTEWATER DISCHARGES: 

If you answered "yes" to question A.8.a, complete questions A.9 through A.12 once for each outfall (including bypass points) through 

which effluent is discharged. Do not include information on combined sewer overflows in this section. If you answered "no" to question 

A.8.a, go to Part B, “Additional Application Information for Applicants with a Design Flow Greater than or Equal to 0.1 mgd.” 

A.9. Description of Outfall.

a. Outfall number 

b. Location 

(City or town, if applicable) (Zip Code) 

 

 (County) (State) 

 

 (Latitude) (Longitude) 

c. Distance from shore (if applicable) ft. 

d. Depth below surface (if applicable) ft. 

e. Average daily flow rate mgd 

f. Does this outfall have either an intermittent or a 

periodic discharge? 

 

Yes 

 

No (go to A.9.g.) 

If yes, provide the following information: 

Number of times per year discharge occurs: 

Average duration of each discharge: 

Average flow per discharge: mgd 

Months in which discharge occurs: 

g. Is outfall equipped with a diffuser? Yes No 

A.10. Description of Receiving Waters.

a. Name of receiving water 

b. Name of watershed (if known) 

 United States Soil Conservation Service 14-digit watershed code (if known): 

c. Name of State Management/River Basin (if known): 

 United States Geological Survey 8-digit hydrologic cataloging unit code (if known): 

d. Critical low flow of receiving stream (if applicable): 

acute cfs chronic ______________ cfs 

e. Total hardness of receiving stream at critical low flow (if applicable): _______________ mg/l of CaCO3
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 6 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

A.11. Description of Treatment.

a. What levels of treatment are provided? Check all that apply. 

 Primary Secondary 

Advanced Other. Describe: 

b. Indicate the following removal rates (as applicable): 

Design BOD5 removal or Design CBOD5 removal % 

Design SS removal % 

Design P removal % 

Design N removal % 

Other % 

c. What type of disinfection is used for the effluent from this outfall? If disinfection varies by season, please describe. 

 

If disinfection is by chlorination, is dechlorination used for this outfall? Yes No 

d. Does the treatment plant have post aeration? Yes No 

A.12. Effluent Testing Information. All Applicants that discharge to waters of the US must provide effluent testing data for the following 

parameters. Provide the indicated effluent testing required by the permitting authority for each outfall through which effluent is 

discharged. Do not include information on combined sewer overflows in this section. All information reported must be based on data 

collected through analysis conducted using 40 CFR Part 136 methods. In addition, this data must comply with 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. 

At a minimum, effluent testing data must be based on at least three samples and must be no more than four and one-half years apart.

Outfall number: 

PARAMETER MAXIMUM DAILY VALUE AVERAGE DAILY VALUE 

Value Units Value Units Number of Samples 

pH (Minimum) s.u. 

pH (Maximum) s.u. 

Flow Rate 

Temperature (Winter) 

Temperature (Summer) 

* For pH please report a minimum and a maximum daily value 

POLLUTANT MAXIMUM DAILY 

DISCHARGE 

AVERAGE DAILY DISCHARGE ANALYTICAL 

METHOD 

ML / MDL 

Conc. Units Conc. Units Number of 

Samples 

CONVENTIONAL AND NONCONVENTIONAL COMPOUNDS. 

BIOCHEMICAL OXYGEN BOD-5 

DEMAND (Report one) CBOD-5 

FECAL COLIFORM 

TOTAL SUSPENDED SOLIDS (TSS) 

END OF PART A. 

REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM 

2A YOU MUST COMPLETE 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 7 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

BASIC APPLICATION INFORMATION 

PART B. ADDITIONAL APPLICATION INFORMATION FOR APPLICANTS WITH A DESIGN FLOW GREATER THAN OR 

EQUAL TO 0.1 MGD (100,000 gallons per day). 

All applicants with a design flow rate > 0.1 mgd must answer questions B.1 through B.6. All others go to Part C (Certification).

B.1. Inflow and Infiltration. Estimate the average number of gallons per day that flow into the treatment works from inflow and/or infiltration. 

 ___________________gpd 

Briefly explain any steps underway or planned to minimize inflow and infiltration. 

______________________________________________________________________________________________________ 

______________________________________________________________________________________________________ 

B.2. Topographic Map. Attach to this application a topographic map of the area extending at least one mile beyond facility property boundaries. 

This map must show the outline of the facility and the following information. (You may submit more than one map if one map does not show 

the entire area.) 

a. The area surrounding the treatment plant, including all unit processes. 

b. The major pipes or other structures through which wastewater enters the treatment works 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 wastewater from the treatment plant is injected underground. 

d. Wells, springs, other surface water bodies, and drinking water wells that are: 1) within 1/4 mile of the property boundaries of the treatment 

works, and 2) listed in public record or otherwise known to the applicant. 

e. Any areas where the sewage sludge produced by the treatment works is stored, treated, or disposed. 

f. If the treatment works receives waste that is classified as hazardous under the Resource Conservation and Recovery Act (RCRA) by 

truck, rail, or special pipe, show on the map where that hazardous waste enters the treatment works and where it is treated, stored, and/or 

disposed. 

B.3. Process Flow Diagram or Schematic. Provide a diagram showing the processes of the treatment plant, including all bypass piping and all 

backup power sources or redundancy in the system. Also provide a water balance showing all treatment units, including disinfection (e.g, 

chlorination and dechlorination). The water balance must show daily average flow rates at influent and discharge points and approximate daily 

flow rates between treatment units. Include a brief narrative description of the diagram. 

B.4. Operation/Maintenance Performed by Contractor(s).

Are any operational or maintenance aspects (related to wastewater treatment and effluent quality) of the treatment works the responsibility of a 

contractor? ____Yes ____No 

If yes, list the name, address, telephone number, and status of each contractor and describe the contractor's responsibilities (attach additional 

pages if necessary). 

 

Name: 

 

Mailing Address: 

 

Telephone Number: 

 

Responsibilities of Contractor: 

B.5. Scheduled Improvements and Schedules of Implementation. Provide information on any uncompleted implementation schedule or 

uncompleted plans for improvements that will affect the wastewater treatment, effluent quality, or design capacity of the treatment works. If the 

treatment works has several different implementation schedules or is planning several improvements, submit separate responses to question 

B.5 for each. (If none, go to question B.6.) 

a. List the outfall number (assigned in question A.9) for each outfall that is covered by this implementation schedule. 

 __________________________________________________________________________ 

b. Indicate whether the planned improvements or implementation schedule are required by local, State, or Federal agencies. 

____Yes ____No 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 8 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

c If the answer to B.5.b is “Yes,” briefly describe, including new maximum daily inflow rate (if applicable). 

 ____________________________________________________________________________________ 

d. Provide dates imposed by any compliance schedule or any actual dates of completion for the implementation steps listed below, as 

applicable. For improvements planned independently of local, State, or Federal agencies, indicate planned or actual completion dates, as 

applicable. Indicate dates as accurately as possible. 

 Schedule Actual Completion 

Implementation Stage MM / DD / YYYY MM / DD / YYYY

– Begin construction ___/ ___/ _____ ___/ ___/ _____ 

– End construction ___/ ___/ _____ ___/ ___/ _____ 

– Begin discharge ___/ ___/ _____ ___/ ___/ _____ 

– Attain operational level ___/ ___/ _____ ___/ ___/ _____ 

e. Have appropriate permits/clearances concerning other Federal/State requirements been obtained? ____Yes ____No 

 Describe briefly: ________________________________________________________ 

 ________________________________________________________ 

B.6. EFFLUENT TESTING DATA (GREATER THAN O.1 MGD ONLY).

Applicants that discharge to waters of the US must provide effluent testing data for the following parameters. Provide the indicated effluent 

testing required by the permitting authority for each outfall through which effluent is discharged. Do not include information on combined sewer 

overflows in this section. All information reported must be based on data collected through analysis conducted using 40 CFR Part 136 

methods. In addition, this data must comply with 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. At a minimum, effluent testing data must be based on at least three 

pollutant scans and must be no more than four and one-half years old. 

Outfall Number:________________ 

POLLUTANT MAXIMUM DAILY 

DISCHARGE 

AVERAGE DAILY DISCHARGE 

Conc. Units Conc. Units Number of 

Samples 

ANALYTICAL 

METHOD 

ML / MDL 

CONVENTIONAL AND NONCONVENTIONAL COMPOUNDS.

AMMONIA (as N) 

CHLORINE (TOTAL 

RESIDUAL, TRC) 

 

DISSOLVED OXYGEN 

TOTAL KJELDAHL 

NITROGEN (TKN) 

NITRATE PLUS NITRITE 

NITROGEN 

OIL and GREASE 

PHOSPHORUS (Total) 

TOTAL DISSOLVED 

SOLIDS (TDS) 

 

OTHER 

END OF PART B. 

REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM 

2A YOU MUST COMPLETE 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 9 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

BASIC APPLICATION INFORMATION

PART C. CERTIFICATION

All applicants must complete the Certification Section. Refer to instructions to determine who is an officer for the purposes of this certification. All 

applicants must complete all applicable sections of Form 2A, as explained in the Application Overview. Indicate below which parts of Form 2A you 

have completed and are submitting. By signing this certification statement, applicants confirm that they have reviewed Form 2A and have completed 

all sections that apply to the facility for which this application is submitted. 

Indicate which parts of Form 2A you have completed and are submitting:

_____ Basic Application Information packet Supplemental Application Information packet: 

 ______ Part D (Expanded Effluent Testing Data) 

 ______ Part E (Toxicity Testing: Biomonitoring Data) 

 ______ Part F (Industrial User Discharges and RCRA/CERCLA Wastes) 

 ______ Part G (Combined Sewer Systems) 

ALL APPLICANTS MUST COMPLETE THE FOLLOWING CERTIFICATION.

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system 

designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons 

who manage the system or those persons directly responsible for gathering the information, the information 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 and official title _____________________________________________________________________________ 

Signature ____________________________________________________________________________ 

Telephone number _____________________________________________________________________________ 

Date signed ______________________________________________________________________________ 

Upon request of the permitting authority, you must submit any other information necessary to assess wastewater treatment practices at the treatment 

works or identify appropriate permitting requirements. 

SEND COMPLETED FORMS TO:
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 10 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

SUPPLEMENTAL APPLICATION INFORMATION 

PART D. EXPANDED EFFLUENT TESTING DATA 

Refer to the directions on the cover page to determine whether this section applies to the treatment works. 

Effluent Testing: 1.0 mgd and Pretreatment Treatment Works. If the treatment works has a design flow greater than or equal to 1.0 mgd or it has 

(or is required to have) a pretreatment program, or is otherwise required by the permitting authority to provide the data, then provide effluent testing 

data for the following pollutants. Provide the indicated effluent testing information and any other information required by the permitting authority for 

each outfall through which effluent is discharged. Do not include information on combined sewer overflows in this section. All information reported 

must be based on data collected through analyses conducted using 40 CFR Part 136 methods. In addition, these data must comply with 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. 

Indicate in the blank rows provided below any data you may have on pollutants not specifically listed in this form. At a minimum, effluent testing data 

must be based on at least three pollutant scans and must be no more than four and one-half years old. 

Outfall number: _________________ (Complete once for each outfall discharging effluent to waters of the United States.) 

POLLUTANT MAXIMUM DAILY 

DISCHARGE 

AVERAGE DAILY DISCHARGE 

Conc. Units Mass Units Conc. Units Mass Units Number 

of 

Samples 

ANALYTICAL 

METHOD 

ML/ MDL 

METALS (TOTAL RECOVERABLE), CYANIDE, PHENOLS, AND HARDNESS.

ANTIMONY 

 

ARSENIC 

BERYLLIUM 

CADMIUM 

CHROMIUM 

COPPER 

LEAD 

MERCURY 

NICKEL 

SELENIUM 

SILVER 

THALLIUM 

ZINC 

CYANIDE 

TOTAL PHENOLIC COMPOUNDS 

HARDNESS (AS CaCO3) 

 

Use this space (or a separate sheet) to provide information on other metals requested by the permit writer. 

 

 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 11 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

Outfall number: _______________ (Complete once for each outfall discharging effluent to waters of the United States.) 

POLLUTANT MAXIMUM DAILY 

DISCHARGE 

AVERAGE DAILY DISCHARGE 

Conc. Units Mass Units Conc. Units Mass Units Number 

of 

Samples 

ANALYTICAL 

METHOD 

ML/ MDL 

VOLATILE ORGANIC COMPOUNDS.

ACROLEIN 

 

ACRYLONITRILE 

BENZENE 

BROMOFORM 

CARBON TETRACHLORIDE 

CLOROBENZENE 

CHLORODIBROMO-METHANE 

CHLOROETHANE 

2-CHLORO-ETHYLVINYL 

ETHER 

CHLOROFORM 

DICHLOROBROMO-METHANE 

1,1-DICHLOROETHANE 

1,2-DICHLOROETHANE 

TRANS-1,2-DICHLORO-ETHYLENE 

1,1-DICHLOROETHYLENE 

1,2-DICHLOROPROPANE 

1,3-DICHLORO-PROPYLENE 

ETHYLBENZENE 

METHYL BROMIDE 

METHYL CHLORIDE 

METHYLENE CHLORIDE 

1,1,2,2-TETRACHLORO-ETHANE 

TETRACHLORO-ETHYLENE 

TOLUENE 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 12 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

Outfall number: _______________ (Complete once for each outfall discharging effluent to waters of the United States.) 

POLLUTANT MAXIMUM DAILY 

DISCHARGE 

AVERAGE DAILY DISCHARGE 

Conc. Units Mass Units Conc. Units Mass Units Number 

of 

Samples 

ANALYTICAL 

METHOD 

ML/ MDL 

1,1,1-TRICHLOROETHANE 

 

1,1,2-TRICHLOROETHANE 

TRICHLORETHYLENE 

VINYL CHLORIDE 

Use this space (or a separate sheet) to provide information on other volatile organic compounds requested by the permit writer.

 

ACID-EXTRACTABLE COMPOUNDS

P-CHLORO-M-CRESOL 

 

2-CHLOROPHENOL 

2,4-DICHLOROPHENOL 

2,4-DIMETHYLPHENOL 

4,6-DINITRO-O-CRESOL 

2,4-DINITROPHENOL 

2-NITROPHENOL 

4-NITROPHENOL 

PENTACHLOROPHENOL 

PHENOL 

2,4,6-TRICHLOROPHENOL 

Use this space (or a separate sheet) to provide information on other acid-extractable compounds requested by the permit writer.

 

BASE-NEUTRAL COMPOUNDS.

ACENAPHTHENE 

 

ACENAPHTHYLENE 

ANTHRACENE 

BENZIDINE 

BENZO(A)ANTHRACENE 

BENZO(A)PYRENE 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 13 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

Outfall number: _______________ (Complete once for each outfall discharging effluent to waters of the United States.) 

POLLUTANT MAXIMUM DAILY 

DISCHARGE 

AVERAGE DAILY DISCHARGE 

Conc. Units Mass Units Conc. Units Mass Units Number 

of 

Samples 

ANALYTICAL 

METHOD 

ML/ MDL 

3,4 BENZO-FLUORANTHENE 

 

BENZO(GHI)PERYLENE 

BENZO(K)FLUORANTHENE 

BIS (2-CHLOROETHOXY) 

METHANE 

BIS (2-CHLOROETHYL)-ETHER 

BIS (2-CHLOROISO-PROPYL) 

ETHER 

BIS (2-ETHYLHEXYL) PHTHALATE 

4-BROMOPHENYL PHENYL ETHER 

BUTYL BENZYL PHTHALATE 

2-CHLORONAPHTHALENE 

4-CHLORPHENYL PHENYL ETHER 

CHRYSENE 

DI-N-BUTYL PHTHALATE 

DI-N-OCTYL PHTHALATE 

DIBENZO(A,H) ANTHRACENE 

1,2-DICHLOROBENZENE 

1,3-DICHLOROBENZENE 

1,4-DICHLOROBENZENE 

3,3-DICHLOROBENZIDINE 

DIETHYL PHTHALATE 

DIMETHYL PHTHALATE 

2,4-DINITROTOLUENE 

2,6-DINITROTOLUENE 

1,2-DIPHENYLHYDRAZINE 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 14 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

Outfall number: _______________ (Complete once for each outfall discharging effluent to waters of the United States.) 

POLLUTANT MAXIMUM DAILY 

DISCHARGE 

AVERAGE DAILY DISCHARGE 

Conc. Units Mass Units Conc. Units Mass Units Number 

of 

Samples 

ANALYTICAL 

METHOD 

ML/ MDL 

FLUORANTHENE 

 

FLUORENE 

HEXACHLOROBENZENE 

HEXACHLOROBUTADIENE 

HEXACHLOROCYCLOPENTADIENE 

HEXACHLOROETHANE 

INDENO(1,2,3-CD)PYRENE 

ISOPHORONE 

NAPHTHALENE 

NITROBENZENE 

N-NITROSODI-N-PROPYLAMINE 

N-NITROSODI- METHYLAMINE 

N-NITROSODI-PHENYLAMINE 

PHENANTHRENE 

PYRENE 

1,2,4-TRICHLOROBENZENE 

Use this space (or a separate sheet) to provide information on other base-neutral compounds requested by the permit writer. 

 

Use this space (or a separate sheet) to provide information on other pollutants (e.g., pesticides) requested by the permit writer. 

 

END OF PART D. 

REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM 

2A YOU MUST COMPLETE 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 15 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

SUPPLEMENTAL APPLICATION INFORMATION 

PART E. TOXICITY TESTING DATA

POTWs meeting one or more of the following criteria must provide the results of whole effluent toxicity tests for acute or chronic toxicity for each of 

the facility’s discharge points: 1) POTWs with a design flow rate greater than or equal to 1.0 mgd; 2) POTWs with a pretreatment program (or those 

that are required to have one under 40 CFR Part 403); or 3) POTWs required by the permitting authority to submit data for these parameters. 

• At a minimum, these results must include quarterly testing for a 12-month period within the past 1 year using multiple species (minimum of 

two species), or the results from four tests performed at least annually in the four and one-half years prior to the application, provided the 

results show no appreciable toxicity, and testing for acute and/or chronic toxicity, depending on the range of receiving water dilution. Do 

not include information on combined sewer overflows in this section. All information reported must be based on data collected through 

analysis conducted using 40 CFR Part 136 methods. In addition, this data must comply with 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. 

• In addition, submit the results of any other whole effluent toxicity tests from the past four and one-half years. If a whole effluent toxicity 

test conducted during the past four and one-half years revealed toxicity, provide any information on the cause of the toxicity or any results 

of a toxicity reduction evaluation, if one was conducted. 

• If you have already submitted any of the information requested in Part E, you need not submit it again. Rather, provide the information 

requested in question E.4 for previously submitted information. If EPA methods were not used, report the reasons for using alternate 

methods. If test summaries are available that contain all of the information requested below, they may be submitted in place of Part E. 

If no biomonitoring data is required, do not complete Part E. Refer to the Application Overview for directions on which other sections of the form to 

complete. 

E.1. Required Tests.

 Indicate the number of whole effluent toxicity tests conducted in the past four and one-half years. 

____chronic ____acute 

E.2. Individual Test Data. Complete the following chart for each whole effluent toxicity test conducted in the last four and one-half years. Allow one 

column per test (where each species constitutes a test). Copy this page if more than three tests are being reported. 

Test number:________ Test number:________ Test number:________ 

a. Test information. 

Test species & test method number 

Age at initiation of test 

Outfall number 

Dates sample collected 

Date test started 

Duration 

b. Give toxicity test methods followed. 

Manual title 

Edition number and year of publication 

Page number(s) 

c. Give the sample collection method(s) used. For multiple grab samples, indicate the number of grab samples used. 

24-Hour composite 

Grab 

d. Indicate where the sample was taken in relation to disinfection. (Check all that apply for each) 

Before disinfection 

After disinfection 

After dechlorination 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 16 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

Test number:________ Test number:________ Test number:________ 

e. Describe the point in the treatment process at which the sample was collected. 

Sample was collected: 

f. For each test, include whether the test was intended to assess chronic toxicity, acute toxicity, or both. 

Chronic toxicity 

Acute toxicity 

g. Provide the type of test performed. 

Static 

Static-renewal 

Flow-through 

h. Source of dilution water. If laboratory water, specify type; if receiving water, specify source. 

Laboratory water 

Receiving water 

i. Type of dilution water. It salt water, specify “natural” or type of artificial sea salts or brine used. 

Fresh water 

Salt water 

j. Give the percentage effluent used for all concentrations in the test series. 

 

k. Parameters measured during the test. (State whether parameter meets test method specifications) 

pH 

Salinity 

Temperature 

Ammonia 

Dissolved oxygen 

l. Test Results. 

Acute: 

Percent survival in 100% 

effluent 

% % % 

LC50

 

95% C.I. % % % 

Control percent survival % % % 

Other (describe) 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 17 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

Chronic: 

NOEC % % % 

IC25 % % % 

Control percent survival % % % 

Other (describe) 

m. Quality Control/Quality Assurance. 

Is reference toxicant data available? 

Was reference toxicant test within 

acceptable bounds? 

 

What date was reference toxicant test 

run (MM/DD/YYYY)? 

Other (describe) 

E.3. Toxicity Reduction Evaluation. Is the treatment works involved in a Toxicity Reduction Evaluation? 

____Yes ____No If yes, describe: ____________________________________________________ 

____________________________________________________________________________________________ 

____________________________________________________________________________________________ 

E.4. Summary of Submitted Biomonitoring Test Information. If you have submitted biomonitoring test information, or information regarding the 

cause of toxicity, within the past four and one-half years, provide the dates the information was submitted to the permitting authority and a 

summary of the results. 

Date submitted: ________________ (MM/DD/YYYY) 

Summary of results: (see instructions) 

____________________________________________________________________________________ 

____________________________________________________________________________________ 

END OF PART E. 

REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM 

2A YOU MUST COMPLETE. 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 18 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

SUPPLEMENTAL APPLICATION INFORMATION 

PART F. INDUSTRIAL USER DISCHARGES AND RCRA/CERCLA WASTES

All treatment works receiving discharges from significant industrial users or which receive RCRA, CERCLA, or other remedial wastes must 

complete Part F. 

GENERAL INFORMATION: 

F.1. Pretreatment Program. Does the treatment works have, or is it subject to, an approved pretreatment program? 

____Yes ____No 

F.2. Number of Significant Industrial Users (SIUs) and Categorical Industrial Users (CIUs). Provide the number of each of the following types 

of industrial users that discharge to the treatment works. 

a. Number of non-categorical SIUs. ____________ 

b. Number of CIUs. ____________ 

SIGNIFICANT INDUSTRIAL USER INFORMATION:

Supply the following information for each SIU. If more than one SIU discharges to the treatment works, copy questions F.3 through F.8 

and provide the information requested for each SIU. 

F.3. Significant Industrial User Information. Provide the name and address of each SIU discharging to the treatment works. Submit additional 

pages as necessary. 

Name: ____________________________________________________________________________________ 

Mailing Address: ____________________________________________________________________________________ 

 ____________________________________________________________________________________ 

 

F.4. Industrial Processes. Describe all of the industrial processes that affect or contribute to the SIU's discharge. 

_______________________________________________________________________________________________________ 

F.5. Principal Product(s) and Raw Material(s). Describe all of the principal processes and raw materials that affect or contribute to the SIU's 

discharge. 

Principal product(s): ________________________________________________________________________________ 

Raw material(s): ________________________________________________________________________________ 

F.6. Flow Rate.

a. Process wastewater flow rate. Indicate the average daily volume of process wastewater discharged into the collection system in gallons 

per day (gpd) and whether the discharge is continuous or intermittent. 

_____________ gpd (_____continuous or ______intermittent) 

b. Non-process wastewater flow rate. Indicate the average daily volume of non-process wastewater flow discharged into the collection 

system in gallons per day (gpd) and whether the discharge is continuous or intermittent. 

_____________ gpd (_____continuous or ______intermittent) 

F.7. Pretreatment Standards. Indicate whether the SIU is subject to the following: 

a. Local limits ____Yes ____No 

b. Categorical pretreatment standards ____Yes ____No 

If subject to categorical pretreatment standards, which category and subcategory? 

_______________________________________________________________________________________________________ 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 19 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

F.8. Problems at the Treatment Works Attributed to Waste Discharged by the SIU. Has the SIU caused or contributed to any problems (e.g., 

upsets, interference) at the treatment works in the past three years? 

____Yes ____No If yes, describe each episode. 

_______________________________________________________________________________________________________ 

_______________________________________________________________________________________________________ 

RCRA HAZARDOUS WASTE RECEIVED BY TRUCK, RAIL, OR DEDICATED PIPELINE:

F.9. RCRA Waste. Does the treatment works receive or has it in the past three years received RCRA hazardous waste by truck, rail, or dedicated

pipe? ____Yes ___No (go to F.12.) 

F.10. Waste Transport. Method by which RCRA waste is received (check all that apply): 

______Truck ______Rail ______Dedicated Pipe 

F.11. Waste Description. Give EPA hazardous waste number and amount (volume or mass, specify units). 

EPA Hazardous Waste Number Amount Units

_________________________ _______________ _______________ 

_________________________ _______________ _______________ 

_________________________ _______________ _______________ 

CERCLA (SUPERFUND) WASTEWATER, RCRA REMEDIATION/CORRECTIVE 

ACTION WASTEWATER, AND OTHER REMEDIAL ACTIVITY WASTEWATER:

F.12. Remediation Waste. Does the treatment works currently (or has it been notified that it will) receive waste from remedial activities? 

 ____Yes (complete F.13 through F.15.) ____No 

 Provide a list of sites and the requested information (F.13 - F.15.) for each current and future site. 

F.13. Waste Origin. Describe the site and type of facility at which the CERCLA/RCRA/or other remedial waste originates (or is expected to originate 

in the next five years). 

_______________________________________________________________________________________________________ 

_______________________________________________________________________________________________________ 

_______________________________________________________________________________________________________ 

F.14. Pollutants. List the hazardous constituents that are received (or are expected to be received). Include data on volume and concentration, if 

known. (Attach additional sheets if necessary). 

_______________________________________________________________________________________________________ 

_______________________________________________________________________________________________________ 

F.15. Waste Treatment.

a. Is this waste treated (or will it be treated) prior to entering the treatment works? 

____Yes ____No 

If yes, describe the treatment (provide information about the removal efficiency): 

____________________________________________________________________________________________________ 

____________________________________________________________________________________________________ 

b. Is the discharge (or will the discharge be) continuous or intermittent? 

____Continuous ____Intermittent If intermittent, describe discharge schedule. 

____________________________________________________________________________________________________ 

END OF PART F. 

REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM 

2A YOU MUST COMPLETE 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 20 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

SUPPLEMENTAL APPLICATION INFORMATION 

PART G. COMBINED SEWER SYSTEMS

If the treatment works has a combined sewer system, complete Part G. 

G.1. System Map. Provide a map indicating the following: (may be included with Basic Application Information) 

a. All CSO discharge points. 

b. Sensitive use areas potentially affected by CSOs (e.g., beaches, drinking water supplies, shellfish beds, sensitive aquatic ecosystems, and 

outstanding natural resource waters). 

c. Waters that support threatened and endangered species potentially affected by CSOs. 

G.2. System Diagram. Provide a diagram, either in the map provided in G.1. or on a separate drawing, of the combined sewer collection system 

that includes the following information: 

a. Locations of major sewer trunk lines, both combined and separate sanitary. 

b. Locations of points where separate sanitary sewers feed into the combined sewer system. 

c. Locations of in-line and off-line storage structures. 

d. Locations of flow-regulating devices. 

e. Locations of pump stations. 

CSO OUTFALLS:

Complete questions G.3 through G.6 once for each CSO discharge point. 

G.3. Description of Outfall.

a. Outfall number ________________________________ 

b. Location ________________________________________________________________ 

 (City or town, if applicable) (Zip Code) 

 ________________________________________________________________ 

 (County) (State) 

 ________________________________________________________________ 

 (Latitude) (Longitude) 

c. Distance from shore (if applicable) ____________ft. 

d. Depth below surface (if applicable) ____________ft. 

e. Which of the following were monitored during the last year for this CSO? 

____Rainfall ____CSO pollutant concentrations ____CSO frequency 

____CSO flow volume ____Receiving water quality 

f. How many storm events were monitored during the last year? _____________ 

G.4. CSO Events.

a. Give the number of CSO events in the last year. 

__________ events (___ actual or ___ approx.) 

b. Give the average duration per CSO event. 

__________ hours (____ actual or ____ approx.) 
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 21 of 21

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

c. Give the average volume per CSO event. 

__________ million gallons (_____ actual or _____ approx.) 

d. Give the minimum rainfall that caused a CSO event in the last year. 

__________ inches of rainfall 

G.5. Description of Receiving Waters.

a. Name of receiving water: ______________________________________________________________________________ 

b. Name of watershed/river/stream system: _______________________________________________________________ 

United States Soil Conservation Service 14-digit watershed code (if known): _______________________________________ 

c. Name of State Management/River Basin: _______________________________________________________________ 

United States Geological Survey 8-digit hydrologic cataloging unit code (if known): ______________________________ 

G.6. CSO Operations.

Describe any known water quality impacts on the receiving water caused by this CSO (e.g., permanent or intermittent beach closings, 

permanent or intermittent shell fish bed closings, fish kills, fish advisories, other recreational loss, or violation of any applicable State water 

quality standard). 

______________________________________________________________________________________________ 

______________________________________________________________________________________________ 

END OF PART G. 

REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM 

2A YOU MUST COMPLETE. 
NPDES FORM 2A Additional Information 

Additional information, if provided, will appear on the following pages. 
Disclaimer 

This is an updated PDF document that allows you to type your information 

directly into the form, print it, and save the completed form. 

Note: This form can be viewed and saved only using Adobe Acrobat Reader 

version 7.0 or higher, or if you have the full Adobe Professional version. 

Instructions: 

1. Type in your information 

2. Save file (if desired) 

3. Print the completed form 

4. Sign and date the printed copy 

5. Mail it to the directed contact. 
Form Approved 

OMB No. 2040-0250 

Approval expires 12-15-05 

EPA I.D. NUMBER (copy from Item 1 of Form 1) 

FORM 

2B 

NPDES 

EPA 

U.S. ENVIRONMENTAL PROTECTION AGENCY 

APPLICATIONS FOR PERMIT TO DISCHARGE WASTEWATER 

CONCENTRATED ANIMAL FEEDING OPERATIONS AND AQUATIC ANIMAL PRODUCTION 

FACILITIES 

I. GENERAL INFORMATION Applying for: Individual Permit G Coverage Under General Permit G

A. TYPE OF BUSINESS B. CONTACT INFORMATION C. FACILITY OPERATION 

STATUS 

“ 1. Concentrated Animal Feeding 

Operation (complete items B, C, D, 

and Section II) 

“ 2. Concentrated Aquatic Animal 

Production Facility (complete items 

B, C, and section III) 

Owner/or 

Operator Name: 

Telephone: ( _____ ) 

Address: 

Facsimile: ( _____ ) 

City: State:_____ Zip Code: 

__________________________________ 

______________________________ 

________________________________________ 

_______________________________ 

______________ _________ 

“ 1. Existing Facility 

“ 2. Proposed Facility 

D. FACILITY INFORMATION 

Name: Telephone: ( _____ ) _____________________________ 

Address: Facsimile: ( _____ ) 

City: __________________________________ State: Zip Code: 

County: _________________________ Latitude: Longitude: 

If contract operation: Name of Integrator: 

Address of Integrator: 

___________________________________________________________ 

_________________________________________________________ _____________________________ 

___________________ _____________________________________ 

_________________________ _______________________________ 

_________________________________________________ 

_______________________________________________ 

II. CONCENTRATED ANIMAL FEEDING OPERATION CHARACTERISTICS 

A. TYPE AND NUMBER OF ANIMALS B. Manure, Litter and/or Wastewater Production and Use 

2. ANIMALS a) How much manure, litter and wastewater is generated 

annually by the facility? tons gallons 

b) If land applied how many acres of land under the control of 

the applicant are available for applying the CAFOs 

manure/litter/wastewater? ____________________ acres 

c) How many tons of manure or litter, or gallons of wastewater produced by the CAFO will be transferred annually 

to other persons? tons/gallons (circle one) 

_____ _______ 

1. TYPE NO. IN OPEN 

CONFINEMENT 

NO. HOUSED 

UNDER ROOF 

“ Mature Dairy Cows 

“ Dairy Heifers 

“ Veal Calves 

“ Cattle (not dairy or veal) 

“ Swine (55 lbs. or over) 

“ Swine (under 55 lbs.) 

“ Horses 

“ Sheep or Lambs 

“ Turkeys 

EPA Form 3510-2B (12-02) 
Form Approved 

OMB No. 2040-0250 

Approval expires 12-15-05 

“ Chickens (Broilers) 

“ Chickens (Layers) 

“ Ducks 

“ Other 

Specify ___________ 

3. TOTAL ANIMALS 

C. “ TOPOGRAPHIC MAP 

D. TYPE OF CONTAINMENT, STORAGE AND CAPACITY 

1. Type of Containment Total Capacity (in gallons) 

“ Lagoon 

“ Holding Pond 

“ Evaporation Pond 

“ Other: Specify _______________ 

2. Report the total number of acres contributing drainage: __________________________ acres 

3. Type of Storage Total Number of 

Days 

Total Capacity 

(gallons/tons) 

“ Anaerobic Lagoon 

“ Storage Lagoon 

“ Evaporation Pond 

“ Aboveground Storage Tanks 

“ Belowground Storage Tanks 

“ Roofed Storage Shed 

“ Concrete Pad 

“ Impervious Soil Pad 

“ Other: Specify _______________ 

E. NUTRIENT MANAGEMENT PLAN 

A. Has a nutrient management plan been developed? G Yes G No 

B. Is a nutrient management plan being implemented for the facility? G Yes G No 

C. If no, when will the nutrient management plan be developed? Date: ____________ 

D. The date of the last review or revision of the nutrient management plan. Date: ____________ 

E. If not land applying, describe alternative use(s) of manure, litter and or wastewater: 

EPA Form 3510-2B (12-02) 
Form Approved 

OMB No. 2040-0250 

Approval expires 12-15-05 

F. LAND APPLICATION BEST MANAGEMENT PRACTICES 

Please check any of the following best management practices that are being implemented at the facility to control runoff and protect water 

quality: 

“ Buffers “ Setbacks “ Conservation tillage “ Constructed wetlands “ Infiltration field “ Grass filter “ Terrace 

III. CONCENTRATED AQUATIC ANIMAL PRODUCTION FACILITY CHARACTERISTICS 

A. For each outfall give the maximum daily flow, maximum 30-day B. Indicate the total number of ponds, raceways, and similar 

flow, and the long-term average flow. structures in your facility. 

1. Outfall No. 2. Flow (gallons per day) 1. Ponds 2. Raceways 3. Other 

a. Maximum b. Maximum c. Long Term 

30 Day Average used by your facility. 

1. Receiving Water 

C. Provide the name of the receiving water and the source of water 

Daily 

2. Water Source 

D. List the species of fish or aquatic animals held and fed at your facility. For each species, give the total weight produced by your facility

per year in pounds of harvestable weight, and also give the maximum weight present at any one time.

1. Cold Water Species 2. Warm Water Species 

a. Species b. Harvestable Weight (pounds) a. Species b. Harvestable Weight (pounds) 

(1) Total Yearly (2) Maximum (1) Total Yearly (2) Maximum 

E. Report the total pounds of food during the calendar month of 1. Month 2. Pounds of Food

maximum feeding.

IV. CERTIFICATION 

A. Name and Official Title (print or type) 

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all

attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the

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

possibility of fine and imprisonment.

B. Phone No. ( ) 

C. Signature D. Date Signed 

EPA Form 3510-2B (12-02) 
Form Approved 

OMB No. 2040-0250 

Approval expires 12-15-05 

INSTRUCTIONS 

GENERAL Item II-D 

This form must be completed by all applicants who check “yes” to 

Item II-B in Form 1. Not all animal feeding operations or fish farms are 

required to obtain NPDES permits. Exclusions are based on size. See the 

description of these statutory and regulatory exclusions in the General 

Instructions that accompany Form 1. 

For aquatic animal production facilities, the size cutoffs are based on 

whether the species are warm water or cold water, on the production 

weight per year in harvestable pounds, and on the amount of feeding in 

pounds of food (for cold water species). Also, facilities which discharge 

less than 30 days per year, or only during periods of excess runoff (for 

warm water fish) are not required to have a permit. 

1. Provide information on the type of containment and the capacity of the 

containment structure (s). 

2. The number of acres that are drained and collected in the containment 

structure (s). 

3. Identify the type of storage for the manure, litter and/or wastewater. 

Give the capacity of this storage in days and gallons or tons. 

Item II-E 

Provide information concerning the status of the development and 

implementation of a nutrient management plan for the facility. In those 

cases where the nutrient management plan has not been completed, 

provide an estimated date of development and implementation. If not 

Refer to the Form 1 instructions to determine where to file this form. land applying, describe the alternative uses of the manure, litter and 

Item I-A 

See the note above and the General Instructions which accompany Form 

1 to be sure that your facility is a “concentrated animal feeding 

operation” (CAFO). 

Item I-B 

Use this space to give owner/operator contact information. 

Item I-C 

Check “proposed” if your facility is not now in operation or is expanding 

to meet the definition of a CAFO in accordance with the information 

found in the General Instructions that accompany Form 1. 

Item I-D 

Use this space to give a complete legal description of your facility’s 

location including name, address, and latitude/longitude. Also, the if a 

contract grower, the name and address of the integrator. 

Item II 

Supply all information in item II if you checked (1) in item I-A. 

Item II-A 

Give the maximum number of each type of animal in open confinement 

or housed under roof (either partially or totally) which are held at your 

facility for a total of 45 days or more in any 12 month period. Provide the 

total number of animals confined at the facility. 

Item II-B 

Provide the total amount of manure, litter and wastewater generated 

annually by the facility. Identify if manure, litter and wastewater 

generated by the facility is to be land applied and the number of acres, 

under the control of the CAFO operator, suitable for land application. If 

the answer to question 3 is yes, provide the estimated annual quantity of 

manure, litter and wastewater that the applicant plans to transfer off-site. 

Item II-C 

Check this box if you have submitted a topographic map of the 

geographic area in which the CAFO is located showing the specific 

location of the production area. 

wastewater (e.g., composting, pelletizing, energy generation, etc.). 

Item II-F 

Check any of the identified conservation practices that are being 

implemented at the facility to control runoff and protect water quality. 

Item III 

Supply all information in Item III if you checked (2) in Item I-A. 

Item III-A 

Outfalls should be numbered to correspond with the map submitted in 

Item XI of Form 1. Values given for flow should be representative of 

your normal operation. The maximum daily flow is the maximum 

measured flow occurring over a calendar day. The maximum 30-day 

flow is the average of measured daily flow over the calendar month of 

highest flow. The long-term average flow is the average of measure daily 

flows over a calendar year. 

Item III-B 

Give the total number of discrete ponds or raceways in your facility. 

Under “other,” give a descriptive name of any structure which is not a 

pond or a raceway but which results in discharge to waters of the United 

States. 

Item III-C 

Use names for receiving water and source of water which correspond to 

the map submitted in Item XI of Form 1. 

Item III-D 

The names of fish species should be proper, common, or scientific names 

as given in special Publication No. 6 of the American Fisheries Society. 

“A List of Common and Scientific Names of Fishes from the United 

States and Canada.” The values given for total weight produced by your 

facility per year and the maximum weight present at any one time should 

be representative of your normal operation. 

Item III-E 

The value given for maximum monthly pounds of food should be 

representative of your normal operation. 

Item IV 

The Clean Water Act provides for severe penalties for submitting false 

information on this application form. 

Section 309(C)(2) of the Clean Water Act provides that “Any person 

who knowingly makes any false statement, representation, or 

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

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

months, or both.” 

Federal regulations require the certification to be signed as follows: 

A. For corporation, by a principal executive officer of at least the level 

of vice president. 

B. For a partnership or sole proprietorship, by a general partner or the 

proprietor, respectively; or 

C. For a municipality, State, Federal, or other public facility, by either 

a principal executive officer or ranking elected official. 

Paper Reduction Act Notice 

The Public reporting burden for this collection of information 

estimated to average 4 hours per response. 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 estimate or any other aspect of this collection of 

information to the chief, Information Policy Branch (PM-223), 

U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, 

N.W., Washington, D.C. 20460, and the Office of Information and 

Regulatory Afairs, Office of Management and Budget, Washington, 

D.C. 20503, marked Attention: Desk Officer for EPA. 

EPA Form 3510-2B (12-02) 
Disclaimer 

This is an updated PDF document that allows you to type your information 

directly into the form, print it, and save the completed form. 

Note: This form can be viewed and saved only using Adobe Acrobat Reader 

version 7.0 or higher, or if you have the full Adobe Professional version. 

Instructions: 

1. Type in your information 

2. Save file (if desired) 

3. Print the completed form 

4. Sign and date the printed copy 

5. Mail it to the directed contact. 
United States 

Environmental Protection 

Agency 

Office of 

Enforcement 

Washington, DC 20460 

EPA Form 3510-2C 

Revised August 1990 

Previous editions 

are obsolete 

Permits Division 

Application Form 2C – 

Wastewater Discharge 

Information 

Consolidated Permits Program 

This form must be completed by all persons applying 

for an EPA permit to discharge wastewater (existing 

manufacturing, commercial, mining, and silvicultural 

operations). 
Paperwork Reduction Act Notice 

The public reporting burden for this collection of information is 

estimated to average 33 hours per response. This estimate 

includes time for reviewing instructions, searching existing 

data sources, gathering and maintaining the needed data, and 

completing and reviewing the collection of information. Send 

comments regarding the burden estimate or any other aspect 

of this collection of information to the Chief, Information Policy 

Branch (PM-223), US Environmental Protection Agency, 

1200 Pennsylvania Avenue, NW, Washington, DC 20460, and 

to the Office of Information and Regulatory Affairs, Office of 

Management and Budget, Washington, DC 20503, marked 

Attention: Desk Officer for EPA. 
INSTRUCTIONS – FORM 2c 

Application for Permit to Discharge Wastewater 

EXISTING MANUFACTURING, COMMERCIAL, MINING. AND SILVICULTURAL OPERATIONS 

2C-1

This form must be completed by all applicants who check “yes” to 

item II-C in Form 1. 

Public Availability of Submitted Information. 

Your application will not be considered complete unless you answer 

every question on this form and on Form 1. If an item does not apply 

to you, enter “NA” (for not applicable) to show that you considered 

the question. 

You may not claim as confidential any information required by this 

form or Form 1, whether the information is reported on the forms or 

in an attachment. This information will be made available to the 

public upon request. 

Any information you submit to EPA which goes beyond that required 

by this form or Form 1 you may claim as confidential, but claims for 

information which is effluent data will be denied. If you do not assert 

a claim of confidentiality at the time of submitting the information, 

EPA may make the information public without further notice to you. 

Claims of confidentiality will be handled in accordance with EPA’s 

business confidentiality regulations at 40 CFR Part 2. 

Definitions 

All significant terms used in these instructions and in the form are 

defined in the glossary found in the General Instructions which 

accompany Form 1. 

EPA ID Number 

Fill in your EPA Identification Number at the top of each page of 

Form 2c. You may copy this number directly from item I of Form 1. 

Item I 

You may use the map you provided for item XI of Form 1 to 

determine the latitude and longitude of each of your outfalls and the 

name of the receiving water. 

Item II-A 

The line drawing should show generally the route taken by water in 

your facility from intake to discharge. Show all operations 

contributing wastewater, including process and production areas, 

sanitary flows, cooling water, and stormwater runoff. You may group 

similar operations into a single unit, labeled to correspond to the 

more detailed listing in item II-B. The water balance should show 

average flows. Show all significant losses of water to products, 

atmosphere, and discharge. You should use actual measurements 

whenever available; otherwise use your best estimate. An example 

of an acceptable line drawing appears in Figure 2c-1 to these 

instructions. 

Item II-B 

List all sources of wastewater to each outfall. Operations may be 

described in general terms (for example, “dye-making reactor” or 

“distillation tower”). You may estimate the flow contributed by each 

source if no date are available. For stormwater discharges you may 

estimate the average flow, but you must indicate the rainfall event 

upon which the estimate is based and the method of estimation. For 

each treatment unit, indicate its size, flow rate, and retention time, 

and describe the ultimate disposal of any solid or liquid wastes not 

discharged. Treatment units should be listed in order and you should 

select the proper code from Table 2c-1 to fill in column 3-b for each 

treatment unit. Insert “XX” into column 3-b if no code corresponds to 

a treatment unit you list. If you are applying for a permit for a 

privately owned treatment works, you must also identify all of your 

contributors in an attached listing. 

Item II-C 

A discharge is intermittent unless it occurs without interruption during 

the operating hours of the facility, except for infrequent shutdowns 

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

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

year. Fill in every applicable column in this item for each source of 

intermittent or seasonal discharges. Base your answers on actual 

data whenever available; otherwise, provide your best estimate. 

Report the highest daily value for flow rate and total volume in the 

“Maximum Daily” columns (columns 4-a-2 and 4-b-2). Report the 

average of all daily values measured during days when discharge 

occurred within the last year in the “Long Term Average” columns 

(columns 4-a-1 and 4-b-1). 

Item III-A 

All effluent guidelines promulgated by EPA appear in the Federal 

Register and are published annually in 40 CFR Subchapter N. A 

guideline applies to you if you have any operations contributing 

process wastewater in any subcategory covered by a BPT, BCT, or 

BAT guideline. If you are unsure whether you are covered by a 

promulgated effluent guideline, check with your EPA Regional office 

(Table 1 in the Form 1 instructions). You must check “yes” if an 

applicable effluent guideline has been promulgated, even if the 

guideline limitations are being contested in court. If you believe that a 

promulgated effluent guideline has been remanded for 

reconsideration by a court and does not apply to your operations, 

you may check “no.” 

Item III-B 

An effluent guideline is expressed in terms of production (or other 

measure of operation) if the limitation is expressed as mass of 

pollutant per operational parameter; for example, “pounds of BOD 

per cubic foot of logs from which bark is removed,” or “pounds of 

TSS per megawatt hour of electrical energy consumed by smelting 

furnace.” An example of a guideline not expressed in terms of a 

measure of operation is one which limits the concentration of 

pollutants. 

Item III-C 

This item must be completed only if you checked “yes” to item III-B. 

The production information requested here is necessary to apply 

effluent guidelines to your facility and you cannot claim it as 

confidential. However, you do not have to indicate how the reported 

information was calculated. Report quantities in the units of 

measurement used in the applicable effluent guideline. The 

production figures provided must be based on actual daily production 

and not on design capacity or on predictions of future operations. To 

obtain alternate limits under 40 CFR 122.45(b)(2)(ii), you must define 

your maximum production capability and demonstrate to the Director 

that your actual production is substantially below maximum 

production capability and that there is a reasonable potential for an 

increase above actual production during the duration of the permit. 

Item IV-A 

If you check “yes” to this question, complete all parts of the chart, or 

attach a copy of any previous submission you have made to EPA 

containing same information. 

Item IV-B 

You are not required to submit a description of future pollution 

control projects if you do not wish to or if none is planned. 

Item V-A, B, C, and D 

The items require you to collect and report data on the pollutants 

discharged for each of your outfalls. Each part of this item addresses 

a different set of pollutants and must be completed in accordance 

with the specific instructions for that part. The following general 

instructions apply to the entire item. 

General Instructions 

Part A requires you to report at least one analysis for each pollutant 

listed. Parts B and C require you to report analytical data in two 

ways. For some pollutants, you may be required to mark “X” in the 

“Testing Required” column (column 2-a, Part C), and test (sample 

and analyze) and report the levels of the pollutants in your discharge 

whether or not you expect them to be present in your discharge. For 

all others, you must mark “X” in either the “Believe Present” column 

or the “Believe Absent” column (columns 2-a or 2-b, Part B, and 

columns 2-b or 2-c, Part C) based on your best estimate, and test for 

those which you believe to be present. (See specific instructions on 

the form and below for Parts A through D.) Base your determination 

that a pollutant is present in or absent from your discharge on your 
FORM 2c – INSTRUCTIONS (continued) 

Item V-A, B, C, and D (continued) 

2C-1

knowledge of your raw materials, maintenance chemicals, 

intermediate and final products and byproducts, and any previous 

analyses known to you of your effluent or similar effluent. (For 

example, if you manufacture pesticides, you should expect those 

pesticides to be present in contaminated stormwater runoff.) If you 

would expect a pollutant to be present solely as a result of its 

presence in your intake water, you must mark “Believe Present” but 

you are not required to analyze for that pollutant. Instead, mark an 

‘X’ In the “Intake” column. 

A. Reporting. All levels must be reported as concentration 

and as total mass. You may report some or all of the 

required data by attaching separate sheets of paper 

instead of filling out pages V-I to V-9 if the separate sheets 

contain all the required information in a format which is 

consistent with pages V-I to V-9 in spacing and in 

identification of pollutants and columns. (For example, the 

data system used in your GC/MS analysis may be able to 

print data in the proper format.) Use the following 

abbreviations in the columns headed “Units” (column 3, 

Part A, and column 4, Parts B and C). 

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

recoverable metal,” unless: 

(1) An applicable, promulgated effluent limitation or standard 

specifies the limitation for the metal in dissolved, valent, or total 

form; or 

(2) All approved analytical methods for the metal inherently 

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

(3) The permitting authority has determined that in establishing 

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

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

carry out the provisions of the CWA. 

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

Daily Values” columns and insert ‘1’ into the “Number of Analyses” 

column (columns 2-a and 2-d, Part A, and column 3-a, 3-d, Parts B 

and C). The permitting authority may require you to conduct 

additional analyses to further characterize your discharges. For 

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

concentration found in a composite sample taken over the operating 

hours of the facility during a 24-hour period; for grab samples, the 

daily value is the arithmetic or flow-weighted total mass or average 

concentration found in a series of at least four grab samples taken 

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

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

values are representative of your wastestream, you must report 

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

You also must determine the average of all values within the last 

year and report the concentration and mass under the “Long Term 

Average Values” columns (column 2-c, Part A, and column 3-c, Parts 

B and C), and the total number of daily values under the “Number of 

Analyses” columns (column 2-d, Part A, and columns 3-d, Parts B 

and C). Also, determine the average of all daily values taken during 

each calendar month, and report the highest average under the 

“Maximum 30-day Values” columns (column 2-c, Part A, and column 

3-b, Parts B and C). 

B. Sampling: The collection of the samples for the reported 

analyses should be supervised by a person experienced in 

performing sampling of industrial wastewater. You may contact your 

EPA or State permitting authority for detailed guidance on sampling 

techniques and for answers to specific questions. Any specific 

requirements contained in the applicable analytical methods should 

be followed for sample containers, sample preservation, holding 

times, the collection of duplicate samples, etc. The time when you 

sample should be representative of your normal operation, to the 

extent feasible, with all processes which contribute wastewater in 

normal operation, and with your treatment system operating properly 

with no system upsets. Samples should be collected from the center 

of the flow channel, where turbulence is at a maximum, at a site 

specified in your present permit, or at any site adequate for the 

collection of a representative sample. 

For pH, temperature, cyanide, total phenols, residual chlorine, oil and 

grease, and fecal coliform, grab samples must be used. For all other 

pollutants 24-hour composite samples must be used. However, a 

minimum of one grab sample may be taken for effluents from holding 

ponds or other impoundments with a retention period of greater than 

24 hours. For stormwater discharges a minimum of one to four grab 

samples may be taken, depending on the duration of the discharge. 

One grab must be taken in the first hour (or less) of discharge, with 

one additional grab (up to a minimum of four) taken in each 

succeeding hour of discharge for discharges lasting four or more 

hours. The Director may waive composite sampling for any outfall for 

which you demonstrate that use of an automatic sampler is infeasible 

and that a minimum of four grab samples will be representative of 

your discharge. 

Grab and composite samples are defined as follows: 

Grab sample: An individual sample of at least 100 milliliters 

collected at a randomly-selected time over a period not exceeding 

15 minutes. 

Composite sample: A combination of at least 8 sample aliquots 

of at least 100 milliliters, collected at periodic intervals during the 

operating hours of a facility over a 24 hour period. The composite 

must be flow proportional; either the time interval between each 

aliquot or the volume of each aliquot must be proportional to either 

the stream flow at the time of sampling or the total stream flow 

since the collection of the previous aliquot. Aliquots may be 

collected manually or automatically. For GC/MS Volatile Organic 

Analysis (VOA), aliquots must be combined in the laboratory 

immediately before analysis. Four (4) (rather than eight ) aliquots 

or grab samples should be collected for VOA. These four samples 

should be collected during actual hours of discharge over a 24-

hour period and need not be flow proportioned. Only one analysis 

is required. 

The Agency is currently reviewing sampling requirements in light of 

recent research on testing methods. Upon completion of its review, 

the Agency plans to propose changes to the sampling requirements. 

Data from samples taken in the past may be used, provided that: 

All data requirements are met; 

Sampling was done no more than three years before submission; 

and 

All data are representative of the present discharge. 

Among the factors which would cause the data to be 

unrepresentative are significant changes in production level, 

changes in raw materials, processes, or final products, and changes 

in wastewater treatment. When the Agency promulgates new 

analytical methods in 40 CFR Part 136, EPA will provide information 

as to when you should use the new methods to generate data on 

your discharges. Of course, the Director may request additional 

information, including current quantitative data, if she or he 

determines it to be necessary to assess your discharges. 

C. Analysis: You must use test methods promulgated in 40 CFR 

Part 136; however, if none has been promulgated for a particular 

pollutant, you may use any suitable method for measuring the level 

of the pollutant in your discharge provided that you submit a 

description of the method or a reference to a published method. Your 

description should include the sample holding time, preservation 

techniques, and the quality control measures which you used. If you 

have two or more substantially identical outfalls, you may request 

permission from your permitting authority to sample and analyse only 

one outfall and submit the results of the analysis for other 

substantially identical outfalls. If your request is granted by the 

Concentration Mass 

ppm.......parts per million lbs.........................pounds 

mg/l ...milligrams per liter ton............tons (English tons)

ppb..........parts per billion mg.......................milligrams 

ug/l ...micrograms per liter g...............................grams 

 kg......................kilograms 

 T...........tonnes (metric tons)
FORM 2c – INSTRUCTIONS (continued) 

Item V-A, B, C, and D (continued) 

2C-1

permitting authority, on a separate sheet attached to the application 

form, identify which outfall you did test, and describe why the outfalls 

which you did not test are substantially identical to the outfall which 

you did test. 

D. Reporting of Intake Data: You are not required to report data 

under the “Intake” columns unless you wish to demonstrate your 

eligibility for a “net” effluent limitation for one or more pollutants, that 

is, an effluent limitation adjusted by subtracting the average level of 

the pollutant(s) present in your intake water, NPDES regulations 

allow net limitations only in certain circumstances. To demonstrate 

your eligibility, under the “Intake” columns report the average of the 

results of analyses on your intake water (if your water is treated 

before use, test the water after it is treated), and discuss the 

requirements for a net limitation with your permitting authority. 

Part V-A 

Part V-A must be completed by all applicants for all outfalls, including 

outfalls containing only noncontact cooling water or storm runoff. 

However, at your request, the Director may waive the requirement to 

test for one or more of these pollutants, upon a determination that 

available information is adequate to support issuance of the permit 

with less stringent reporting requirements for these pollutants. You 

also may request a waiver for one or more of these pollutants for 

your category or subcategory from the Director, Office of Water 

Enforcement and Permits. See discussion in General Instructions to 

item V for definitions of the columns in Part A. The “Long Term 

Average Values” column (column 2-c) and “Maximum 30-day 

Values” column (column 2-b) are not compulsory but should be filled 

out if data are available. 

Use composite samples for all pollutants in this Part, except use grab 

samples for pH and temperature. See discussion in General 

Instructions to Item V for definitions of the columns in Part A. The 

“Long Term Average Values” column (column 2-c) and “Maximum 

30-Day Values” column (column 2-b) are not compulsory but should 

be filled out if data are available. 

Part V-B 

Part V-B must be completed by all applicants for all outfalls, including 

outfalls containing only noncontact cooling water or storm runoff. You 

must report quantitative data if the pollutant(s) in question is limited 

in an effluent limitations guideline either directly, or indirectly but 

expressly through limitation on an indicator (e.g., use of TSS as an 

indicator to control the discharge of iron and aluminum). For other 

discharged pollutants you must provide quantitative data or explain 

their presence in your discharge. EPA will consider requests to the 

Director of the Office of Water Enforcement and Permits to eliminate 

the requirement to test for pollutants for an industrial category or 

subcategory. Your request must be supported by data representative 

of the industrial category or subcategory in question. The data must 

demonstrate that individual testing for each applicant is unnecessary, 

because the facilities in the category or subcategory discharge 

substantially identical levels of the pollutant or discharge the 

pollutant uniformly at sufficiently low levels. Use composite samples 

for all pollutants you analyze for in this part, except use grab 

samples for residual chlorine, oil and grease, and fecal coliform. The 

“Long Term Average Values” column (column 3-c) and “Maximum 

30-day Values” column (column 3-b) are not compulsory but should 

be filled out if data are available. 

Part V-C 

Table 2c-2 lists the 34 “primary” industry categories in the lefthand 

column. For each outfall, if any of your processes which contribute 

wastewater falls into one of those categories, you must mark “X” in 

“Testing Required” column (column 2-a) and test for (l) all of the toxic 

metals, cyanide, and total phenols, and (2) the organic toxic 

pollutants contained in Table 2c-2 as applicable to your category, 

unless you qualify as a small business (see below). The organic toxic 

pollutants are listed by GC/MS fractions on pages V-4 to V-9 in Part 

V-C. For example, the Organic Chemicals Industry has an asterisk in 

all four fractions; therefore, applicants in this category must test for 

all organic toxic pollutants in Part V-C. The inclusion of total phenols 

in Part V-C is not intended to classify total phenols as a toxic 

pollutant. If you are applying for a permit for a privately owned 

treatment works, determine your testing requirements on the basis of 

the industry categories of your contributors. When you determine 

which industry category you are in to find your testing requirements, 

you are not determining your category for any other purpose and you 

are not giving up your right to challenge your inclusion in that 

category (for example, for deciding whether an effluent guideline is 

applicable) before your permit is issued. For all other cases 

(secondary industries, nonprocess wastewater outfalls, and 

nonrequired GC/MS fractions), you must mark “X” in either the 

“Believed Present” column (column 2-b) or the “Believed Absent” 

column (column 2-c) for each pollutant. For every pollutant you know 

or have reason to believe is present in your discharge in 

concentrations of 10 ppb or greater, you must report quantitative 

data. For acrolein, acrylonitrile, 2, 4 dinitrophenol, and 2-methyl-4, 6 

dinitrophenol, where you expect these four pollutants to be 

discharged in concentrations of 100 ppb or greater, you must report 

quantitative data. For every pollutant expected to be discharged in 

concentrations less than the thresholds specified above, you must 

either submit quantitative data or briefly describe the reasons the 

pollutant is expected to be discharged. At your request the Director, 

Office of Water Enforcement and Permits, may waive the 

requirement to test for pollutants for an industrial category or 

subcategory. Your request must be supported by data 

representatives of the industrial category or subcategory in question. 

The data must demonstrate that individual testing for each applicant 

is unnecessary, because the facilities in question discharge 

substantially identical levels of the pollutant, or discharge the 

pollutant uniformly at sufficiently low levels. If you qualify as a small 

business (see below) you are exempt from testing for the organic 

toxic pollutants, listed on pages V-4 to V-9 in Part C. For pollutants in 

intake water, see discussion in General Instructions to this item. The 

“Long Term Average Values” column (column 3-c) and “Maximum 

30-day Values” column (column 3-b) are not compulsory but should 

be filled out if data are available. You are required to mark “Testing 

Required” for dioxin if you use or manufacture one of the following 

compounds: 

(a) 2,4,5-trichlorophenoxy acetic acid, (2,4,5-T); 

(b) 2-(2,4,5-trichlorophenoxy) propanoic acid, (Silvex, 2,4,5-TP) 

(c) 2-(2,4,5-trichlorophenoxy) ethyl 2,2-dichloropropionate, (Erbon); 

(d) 0,0-dimethyl 0-(2,4,5-trichlorophenyl) phosphorothioate, (Ronnel); 

(e) 2,4,5,-trichlorophenol, (TCP); or 

(f) hexachlorophene, (HCP). 

If you mark “Testing Required” or “Believed Present,” you must 

perform a screening analysis for dioxins, using gas chromotography 

with an electron capture detector. A TCDD standard for quantitation 

is not required. Describe the results of this analysis in the space 

provided; for example, “no measurable baseline deflection at the 

retention time of TCDD” or “a measurable peak within the tolerances 

of the retention time of TCDD.” The permitting authority may require 

you to perform a quantitative analysis if you report a positive result. 

The Effluent Guidelines Division of EPA has collected and analyzed 

samples from some plants for the pollutants listed in Part C in the 

course of its BAT guidelines development program. If your effluents 

are sampled and analyzed as part of this program in the last three 

years, you may use these data to answer Part C provided that the 

permitting authority approves, and provided that no process change 

or change in raw materials or operating practices has occurred since 

the samples were taken that would make the analyses 

unrepresentative of your current discharge. 

Small Business Exemption: If you qualify as a “small business”, 

you are exempt from the reporting requirements for the organic toxic 

pollutants, listed on pages V-4 to V-9 in Part C. There are two ways 

in which you can qualify as a “small business.” If your facility is a coal 

mine, and if your probable total annual production is less than 

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

estimated future production (such as a schedule of estimated total 

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

analyses for the organic toxic pollutants. If your facility is not a coal 

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

years average less than $100,000 per year (in second quarter 1980 
FORM 2c – INSTRUCTIONS (continued) 

Item V-A, B, C, and D (continued) 

2C-2

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

conducting analyses for the organic toxic pollutants. The production 

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

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

the process or processes which contribute to the discharge, unless 

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

situations involving intracorporate transfer of goods and services, the 

transfer price per unit should approximate market prices for those 

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

after 1980 should be indexed to the second quarter of 1980 by using 

the gross national product price deflator (second quarter of 

1980=100). This index is available in National Income and Product 

Accounts of the United States (Department of Commerce, Bureau of 

Economic Analysis). 

Part V-D 

List any pollutants in Table 2c-3 that you believe to be present and 

explain why you believe them to be present. No analysis is required, 

but if you have analytical data, you must report it. 

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

substances (listed in Table 2c-4 of these instructions) may be 

exempted from the requirements of section 311 of CWA, which 

establishes reporting requirements, civil penalties and liability for 

cleanup costs for spills of oil and hazardous substances. A discharge 

of a particular substance may be exempted if the origin, source, and 

amount of the discharged substances are identified in the NDPES 

permit application or in the permit, if the permit contains a 

requirement for treatment of the discharge, and if the treatment is in 

place. To apply for an exclusion of the discharge of any hazardous 

substance from the requirements of section 311, attach additional 

sheets of paper to your form, setting forth the following information: 

1. The substance and the amount of each substance which may 

be discharged. 

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

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

a. An onsite treatment system separate from any treatment 

system treating your normal discharge; 

b. A treatment system designed to treat your normal 

discharge and which is additionally capable of treating the 

amount of the substance identified under paragraph 1 

above; or 

c. Any combination of the above. 

See 40 CFR §117.12(a)(2) and (c) published on August 29, 1979, in 

44 FR 50766, or contact your Regional Office (Table 1 on Form 1, 

Instructions), for further information on exclusions from section 311. 

Item VI 

This requirement applies to current use or manufacture of a toxic 

pollutant as an intermediate or final product or byproduct. The 

Director may waive or modify the requirement if you demonstrate 

that it would be unduly burdensome to identify each toxic pollutant 

and the Director has adequate information to issue your permit. You 

may not claim this information as confidential; however, you do not 

have to distinguish between use or production of the pollutants or list 

the amounts. 

Item VII 

Self explanatory. The permitting authority may ask you to provide 

additional details after your application is received. 

Item IX 

The Clean Water Act provides for severe penalties for submitting 

false information on this application form. 

Section 309(c)(2) of the Clean Water Act provides that “Any person 

who knowingly makes any false statement, representation, or 

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

by a fine of not more than $10,000 or by imprisonment for not more 

than six months, or by both.” 

40 CFR Part 122.22 requires the certification to be signed as follows: 

(A) For a corporation: by a responsible corporate official. For 

purposes of this section, a responsible corporate official means (i) a 

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

charge of a principal business function, or any other person who 

performs similar policy- or decision-making functions for the 

corporation, or (ii) the manager of one or more manufacturing, 

production, or operating facilities employing more than 250 persons 

or having gross annual sales or expenditures exceeding $25,000,000 

(in second-quarter 1980 dollars), if authority to sign documents has 

been assigned or delegated to the manager in accordance with 

corporate procedures. 

Note: EPA does not require specific assignments or delegation of 

authority to responsible corporate officers identified in 

§122.22(a)(1)(i). The Agency will presume that these responsible 

corporate officers have the requisite authority to sign permit 

applications unless the corporation has notified the director to the 

contrary. Corporate procedures governing authority to sign permit 

applications may provide for assignment or delegation to applicable 

corporate position under §122.22(a)(1)(ii) rather than to specific 

individuals. 

(B) For a partnership or sole proprietorship: by a general partner or 

the proprietor, respectively; or 

(C) For a municipality, State, Federal, or other public agency: by 

either a principal executive officer or ranking elected official. For 

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

Agency includes (i) the chief executive officer of the Agency, or (ii) a 

senior executive officer having responsibility for the overall 

operations of a principal geographic unit of the Agency (e.g., 

Regional Administrators of EPA). Applications for Group II 

stormwater dischargers may be signed by a duly authorized 

representative (as defined in 40 CFR 122.22(b)) of the individuals 

identified above. 
CODES FOR TREATMENT UNITS 

Table 2C-1

PHYSICAL TREATMENT PROCESSES

1–A. . . . . . . . . . Ammonia Stripping 1–M . . . . . . . . . . Grit Removal 

1–B . . . . . . . . . . Dialysis 1–N . . . . . . . . . . Microstraining 

1–C . . . . . . . . . . Diatomaceous Earth Filtration 1–O . . . . . . . . . . Mixing 

1–D . . . . . . . . . . Distillation 1–P . . . . . . . . . . . Moving Bed Filters 

1–E . . . . . . . . . Electrodialysis 1–Q. . . . . . . . . . . Multimedia Filtration 

1–F . . . . . . . . . Evaporation 1–R . . . . . . . . . . Rapid Sand Filtration 

1–G . . . . . . . . . . Flocculation 1–S . . . . . . . . . . . Reverse Osmosis (Hyperfiltration) 

1–H . . . . . . . . . . Flotation 1–T . . . . . . . . . . . Screening 

1–I . . . . . . . . . . Foam Fractionation 1–U . . . . . . . . . . Sedimentation (Settling) 

1–J . . . . . . . . . . Freezing 1–V . . . . . . . . . . . Slow Sand Filtration 

1–K . . . . . . . . . . Gas–Phase Separation 1–W . . . . . . . . . . Solvent Extraction 

1–L . . . . . . . . . . Grinding (Comminutors) 1–X . . . . . . . . . . . Sorption 

CHEMICAL TREATMENT PROCESSES

2–A . . . . . . . . . . Carbon Adsorption 2–G . . . . . . . . . . Disinfection (Ozone) 

2–B . . . . . . . . . . Chemical Oxidation 2–H . . . . . . . . . . Disinfection (Other) 

2–C . . . . . . . . . . Chemical Precipitation 2–I . . . . . . . . . . . Electrochemical Treatment 

2–D . . . . . . . . . . Coagulation 2–J . . . . . . . . . . . Ion Exchange 

2–E . . . . . . . . . . Dechlorination 2–K . . . . . . . . . . . Neutralization 

2–F . . . . . . . . . . Disinfection (Chlor ine) 2–L . . . . . . . . . . . Reduction 

BIOLOGICAL TREATMENT PROCESSES

3–A . . . . . . . . . . Activated Sludge 3–E . . . . . . . . . . . Pre-Aeration 

3–B . . . . . . . . . . Aerated Lagoons 3–F . . . . . . . . . . . Spray Irrigation/Land Application 

3–C . . . . . . . . . . Anaerobic Treatment 3–G . . . . . . . . . . Stabilization Ponds 

3–D . . . . . . . . . . Nitrification–Denitrification 3–H . . . . . . . . . . Trickling Filtration 

OTHER PROCESSES

4–A . . . . . . . . . . Discharge to Surface Water 4–C . . . . . . . . . . Reuse/Recycle of Treated Effluent 

4–B . . . . . . . . . . Ocean Discharge Through Outfall 4-D . . . . . . . . . . . Underground Injection 

SLUDGE TREATMENT AND DISPOSAL PROCESSES

5–A . . . . . . . . . . Aerobic Digestion 5–M . . . . . . . . . . Heat Drying 

5–B . . . . . . . . . . Anaerobic Digestion 5–N . . . . . . . . . . Heat Treatment 

5–C. . . . . . . . . . Belt Filtration 5–O . . . . . . . . . . Incineration 

5–D. . . . . . . . . . Centrifugation 5–P . . . . . . . . . . . Land Application 

5–E . . . . . . . . . . Chemical Conditioning 5–Q . . . . . . . . . . Landfill 

5–F . . . . . . . . . . Chlorine Treatment 5–R . . . . . . . . . . Pressure Filtration 

5–G . . . . . . . . . . Composting 5–S . . . . . . . . . . Pyrolysis 

5–H . . . . . . . . . . Drying Beds 5–T . . . . . . . . . . Sludge Lagoons 

5–I. . . . . . . . . . . Elutriation 5–U . . . . . . . . . . Vacuum Filtration 

5–J . . . . . . . . . . Flotation Thickening 5–V . . . . . . . . . . Vibration 

5–K . . . . . . . . . . Freezing 5–W . . . . . . . . . . Wet Oxidation 

5–L . . . . . . . . . . Gravity Thickening 
TESTING REQUIREMENTS FOR ORGANIC TOXIC POLLUTANTS INDUSTRY CATEGORY*

Tabe 2C-2

GC/MS FRACTION1

INDUSTRY CATEGORY

Volatile Acid Base/Neutral Pesticide

 

Adhesives and sealants............................................................ X X X – 

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

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

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

Coal mining ............................................................................... X X X X 

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

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

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

Electroplating ............................................................................ X X X – 

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

Foundries .................................................................................. X X X – 

Gum and wood chemicals......................................................... X X X X 

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

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

Leather tanning and finishing.................................................... X X X X 

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

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

Ore mining ................................................................................ X X X X 

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

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

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

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

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

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

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

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

Porcelain enameling ................................................................. X – X X 

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

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

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

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

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

Textile mills ............................................................................... X X X X 

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

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

industry categories. 

1

The pollutants in each fraction are listed in Item V-C.

X = Testing required.

– = Testing not required. 
TOXIC POLLUTANTS AND HAZARDOUS SUBSTANCES 

REQUIRED TO BE IDENTIFIED BY APPLICANTS IF EXPECTED TO BE PRESENT 

Table 2C-3

TOXIC POLLUTANT HAZARDOUS SUBSTANCES HAZARDOUS SUBSTANCES 

Asbestos Dichlorvos Naled 

Diethyl amine Napthenic acid 

HAZARDOUS SUBSTANCES Dimethyl amine Nitrotoluene 

Dintrobenzene Parathion 

Acetaldehyde Diquat Phenolsulfonate 

Allyl alcohol Disulfoton Phosgene 

Allyl chloride Diuron Propargite 

Amyl acetate Epichlorohydrin Propylene oxide 

Aniline Ethion Pyrethrins 

Benzonitrile Ethylene diamine Quinoline 

Benzyl chloride Ethylene dibromide Resorcinol 

Butyl acetate Formaldehyde Strontium 

Butylamine Furfural Strychnine 

Captan Guthion Styrene 

Carbaryl Isoprene 2,4,5-T (2,4,5-Trichlorophenoxyacetic acid) 

Carbofuran Isopropanolamine TDE (Tetrachlorodiphenyl ethane) 

Carbon disulfide Kelthane 2,4,5-TP [2-(2,4,5-Trichlorophenoxy) propanoic acid] 

Chlorpyrifos Kepone Trichlorofon 

Coumaphos Malathion Triethanolamine 

Cresol Mercaptodimethur Triethylamine 

Crotonaldehyde Methoxychlor Trimethylamine 

Cyclohexane Methyl mercaptan Uranium 

2,4-D (2,4-Dichlorophenoxyacetic acid) Methyl methacrylate Vanadium 

Diazinon Methyl parathion Vinyl acetate 

Dicamba Mevinphos Xylene 

Dichlobenil Mexacarbate Xylenol 

Dichlone Monoethyl amine Zirconium 

2,2-Dichloropropionic acid Monomethyl amine 
HAZARDOUS SUBSTANCES 

Table 2C-4

1. Acetaldehyde 

2. Acetic acid 

3. Acetic anhydride 

4. Acetone cyanohydrin 

5. Acetyl bromide 

6. Acetyl chloride 

7. Acrolein 

8. Acrylonitrile 

9. Adipic acid 

10. Aldrin 

11. Allyl alcohol 

12. Allyl chloride 

13. Aluminum sulfate 

14. Ammonia 

15. Ammonium acetate 

16. Ammonium benzoate 

17. Ammonium bicarbonate 

18. Ammonium bichromate 

19. Ammonium bifluoride 

20. Ammonium bisulfite 

21. Ammonium carbamate 

22. Ammonium carbonate 

23. Ammonium chloride 

24. Ammonium chromate 

25. Ammonium citrate 

26. Ammonium fluoroborate 

27. Ammonium fluoride 

28. Ammonium hydroxide 

29. Ammonium oxalate 

30. Ammonium silicofluoride 

31. Ammonium sulfamate 

32. Ammonium sulfide 

33. Ammonium sulfite 

34. Ammonium tartrate 

35. Ammonium thiocyanate 

36. Ammonium thiosulfate 

37. Amyl acetate 

38. Aniline 

39. Antimony pentachloricle 

40. Antimony potassium tartrate 

41. Antimony tribromide 

42. Antimony trichloride 

43. Antimony trifluoride 

44. Antimony trioxide 

45. Arsenic disulfide 

46. Arsenic pentoxide 

47. Arsenic trichloride 

48. Arsenic trioxide 

49. Arsenic trisulfide 

50. Barium cyanide 

51. Benzene 

52. Benzoic acid 

53. Benzonitrile 

54. Benzoyl chloride 

55. Benzyl chloride 

56. Beryllium chloride 

57. Beryllium fluoride 

58. Beryllium nitrate 

59. Butylacetate 

60. n-Butylphthalate 

61. Butylamine 

62. Butyric acid 

63. Cadmium acetate 

64. Cadmium bromide 

65. Cadmium chloride 

66. Calcium arsenate 

67. Calcium arsenite 

69. Calcium carbide 

69. Calcium chromate 

70. Calcium cyanide 

71. Calcium dodecylbenzenesulfonate 

72. Calcium hypochlorite 

73. Captan 

74. Carbaryl 

75. Carbofuran 

76. Carbon disulfide 

77. Carbon tetrachloride 

78. Chlordane 

79. Chlorine 

80. Chlorobenzene 

81. Chloroform 

82. Chloropyrifos 

83. Chlorosulfonic acid 

84. Chromic acetate 

85. Chromic acid 

86. Chromic sulfate 

87. Chromous chloride 

88. Cobaltous bromide 

89. Cobaltous formate 

90. Cobaltous sulfamate 

91. Coumaphos 

92. Cresol 

93. Crotonaldehyde 

94. Cupric acetate 

95. Cupric acetoarsenite 

96. Cupric chloride 

97. Cupric nitrate 

98. Cupric oxalate 

99. Cupric sulfate 

100. Cupric sulfate ammoniated 

101. Cupric tartrate 

102. Cyanogen chloride 

103. Cyclohexane 

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

acid) 

105. 2,4-D esters (2,4- Dichlorophenoxyacetic 

acid esters) 

106. DDT 

107. Diazinon 

108. Dicamba 

109. Dichlobenil 

110. Dichlone 

111. Dichlorobenzene 

112. Dichloropropane 

113. Dichloropropene 

114. Dichloropropene-dichloproropane mix 

115. 2,2-Dichloropropionic acid 

116. Dichlorvos 

117. Dieldrin 

118. Diethylamine 

119. Dimethylamine 

120. Dinitrobenzene 

121. Dinitrophenol 

122. Dinitrotoluene 

123. Diquat 

124. Disulfoton 

125. Diuron 

126. Dodecylbenzesulfonic acid 

127. Endosulfan 

128. Endrin 

129. Epichlorohydrin 

130. Ethion 

131. Ethylbenzene 

132. Ethylenediamine 

133. Ethylene dibromide 

134. Ethylene dichloride 

135. Ethylene diaminetetracetic acid (EDTA) 

136. Ferric ammonium citrate 

137. Ferric ammonium oxalate 

138. Ferric chloride 

139. Ferric fluoride 

140. Ferric nitrate 

141. Ferric sulfate 

142. Ferrous ammonium sulfate 

143. Ferrous chloride 

144. Ferrous sulfate 

145. Formaldehyde 

146. Formic acid 

147. Fumaric acid 

148. Furfural 

149. Guthion 

150. Heptachlor 

151. Hexachlorocyclopentadiene 

152. Hydrochloric acid 

153. Hydrofluoric acid 

154. Hydrogen cyanide 

155. Hydrogen sulfide 

156. Isoprene 

157. Isopropanolamine 

dodecylbenzenesulfonate 

158. Kelthane 

159. Kepone 

160. Lead acetate 

161. Lead arsenate 

162. Lead chloride 

163. Lead fluoborate 

164. Lead flourite 

165. Lead iodide 

166. Lead nitrate 

167. Lead stearate 

168. Lead sulfate 

169. Lead sulfide 

170. Lead thiocyanate 

171. Lindane 

172. Lithium chromate 

173. Malathion 

174. Maleic acid 

175. Maleic anhydride 

176. Mercaptodimethur 

177. Mercuric cyanide 

178. Mercuric nitrate 

179. Mercuric sulfate 

180. Mercuric thiocyanate 

181. Mercurous nitrate 

182. Methoxychlor 

183. Methyl mercaptan 

184. Methyl methacrylate 

185. Methyl parathion 

186. Mevinphos 

187. Mexacarbate 

188. Monoethylamine 

189. Monomethylamine 

190. Naled 

191. Naphthalene 

192. Naphthenic acid 

193. Nickel ammonium sulfate 

194. Nickel chloride 

195. Nickel hydroxide 

196. Nickel nitrate 

197. Nickel sulfate 

198. Nitric acid 

199. Nitrobenzene 

200. Nitrogen dioxide 

201. Nitrophenol 

202. Nitrotoluene 

203. Paraformaldehyde 

204. Parathion 

205. Pentachlorophenol 

206. Phenol 

207. Phosgene 

208. Phosphoric acid 

209. Phosphorus 

210. Phosphorus oxychloride 

211. Phosphorus pentasulfide 

212. Phosphorus trichloride 

213. Polychlorinated biphenyls (PCB) 

214. Potassium arsenate 

215. Potassium arsenite 

216. Potassium bichromate 
HAZARDOUS SUBSTANCES 

Table 2C-4 (continued) 

217. Potassium chromate 

218. Potassium cyanide 

219. Potassium hydroxide 

220. Potassium permanganate 

221. Propargite 

222. Propionic acid 

223. Propionic anhydride 

224. Propylene oxide 

225. Pyrethrins 

226. Quinoline 

227. Resorcinol 

228. Selenium oxide 

229. Silver nitrate 

230. Sodium 

231. Sodium arsenate 

232. Sodium arsenite 

233. Sodium bichromate 

234. Sodium bifluoride 

235. Sodium bisulfite 

236. Sodium chromate 

237. Sodium cyanide 

238. Sodium dodecylbenzenesulfonate 

239. Sodium fluoride 

240. Sodium hydrosulfide 

241. Sodium hydroxide 

242. Sodium hypochlorite 

243. Sodium methylate 

244. Sodium nitrite 

245. Sodium phosphate (dibasic) 

246. Sodium phosphate (tribasic) 

247. Sodium selenite 

248. Strontium chromate 

249. Strychnine 

250. Styrene 

251. Sulfuric acid 

252. Sulfur monochloride 

253. 2,4,5-T acid (2,4,5- 

Trichlorophenoxyacetic acid) 

254. 2,4,5-T amines (2,4,5-Trichlorophenoxy 

acetic acid amines) 

255. 2,4,5-T esters (2,4,5 Trichlorophenoxy 

acetic acid esters) 

256. 2,4,5-T salts (2,4,5-Trichlorophenoxy 

acetic acid salts) 

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

propanoic acid) 

258. 2,4,5-TP acid esters (2,4,5- 

Trichlorophenoxy propanoic acid esters) 

259. TDE (Tetrachlorodiphenyl ethane) 

260. Tetraethyl lead 

261. Tetraethyl pyrophosphate 

262. Thallium sulfate 

263. Toluene 

264. Toxaphene 

265. Trichlorofon 

266. Trichloroethylene 

267. Trichlorophenol 

268. Triethanolamine 

dodecylbenzenesulfonate 

269. Triethylamine 

270. Trimethylamine 

271. Uranyl acetate 

272. Uranyl nitrate 

273. Vanadium penoxide 

274. Vanadyl sulfate 

275. Vinyl acetate 

276. Vinylidene chloride 

277. Xylene 

278. Xylenol 

279. Zinc acetate 

280. Zinc ammonium chloride 

281. Zinc borate 

282. Zinc bromide 

283. Zinc carbonate 

284. Zinc chloride 

285. Zinc cyanide 

286. Zinc fluoride 

287. Zinc formate 

288. Zinc hydrosulfite 

289. Zinc nitrate 

290. Zinc phenolsulfonate 

291. Zinc phosphide 

292. Zinc silicofluoride 

293. Zinc sulfate 

294. Zirconium nitrate 

295. Zirconium potassium flouride 

296. Zirconium sulfate 

297. Zirconium tetrachloride 
LINE DRAWING 

Figure 2C-1 

Fiber

Preparation Dyeing Washing Drying 

Grit 

Separator

Neutralization

Tank

Waste

Treatment

Plant #2

Waste

Treatment

Plant #1

20,000

GPD

10,000

GPD

15,000

GPD

45,000 GPD 45,000 GPD

90,000 GPD

Blue River Municipal

Water Supply

30,000 GPD

Blue River

10,000 GPD

Cooling Water

5,000 GPD

To Atmosphere 10,000 GPD

Raw Materials

To Product 

5,000 GPD 10,000

GPD

40,000

GPD

Outfall 002

50,000 GPD

Loss 

6,000 GPD

Solid Waste

4,000 GPD

40,000 GPD 40,000 GPD

36,000 GPD 34,000 GPD

Outfall 001

Stormwate 70,000 GPD + Stormwater r

Max: 20,000 GPD

Schematic of Water Flow 

Brown Mills, Inc. 

City, County, State 
Please print or type in the unshaded areas only. 

EPA I.D. NUMBER (copy from Item 1 of Form 1) Form Approved. 

OMB No. 2040-0086. 

Approval expires 3-31-98. 

FORM 

2C 

NPDES

U.S. ENVIRONMENTAL PROTECTION AGENCY 

APPLICATION FOR PERMIT TO DISCHARGE WASTEWATER 

EXISTING MANUFACTURING, COMMERCIAL, MINING AND SILVICULTURE OPERATIONS 

Consolidated Permits Program 

I. OUTFALL LOCATION 

For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water. 

A. OUTFALL NUMBER B. LATITUDE C. LONGITUDE 

(list) 1. DEG. 2. MIN. 3. SEC. 1. DEG. 2. MIN. 3. SEC. D. RECEIVING WATER (name) 

 

II. FLOWS, SOURCES OF POLLUTION, AND TREATMENT TECHNOLOGIES 

A. Attach a line drawing showing the water flow through the facility. Indicate sources of intake water, operations contributing wastewater to the effluent, and treatment units 

labeled to correspond to the more detailed descriptions in Item B. Construct a water balance on the line drawing by showing average flows between intakes, operations, 

treatment units, and outfalls. If a water balance cannot be determined (e.g., for certain mining activities), provide a pictorial description of the nature and amount of any 

sources of water and any collection or treatment measures. 

B. For each outfall, provide a description of: (1) All operations contributing wastewater to the effluent, including process wastewater, sanitary wastewater, cooling water, 

and storm water runoff; (2) The average flow contributed by each operation; and (3) The treatment received by the wastewater. Continue on additional sheets if 

necessary. 

2. OPERATION(S) CONTRIBUTING FLOW 3. TREATMENT 1. OUTFALL 

NO. (list) a. OPERATION (list) 

b. AVERAGE FLOW 

(include units) a. DESCRIPTION 

b. LIST CODES FROM 

TABLE 2C-1 

 

 

 

 

 

 

 

OFFICIAL USE ONLY (effluent guidelines sub-categories) 

EPA Form 3510-2C (8-90) PAGE 1 of 4 CONTINUE ON REVERSE 
CONTINUED FROM THE FRONT 

C. Except for storm runoff, leaks, or spills, are any of the discharges described in Items II-A or B intermittent or seasonal? 

YES (complete the following table) NO (go to Section III) 

3. FREQUENCY 4. FLOW 

a. FLOW RATE (in mgd) 

B. TOTAL VOLUME 

(specify with units) 

1. OUTFALL 

NUMBER (list) 

2. OPERATION(s) 

CONTRIBUTING FLOW 

(list) 

a. DAYS PER 

WEEK 

(specify 

average)

b. MONTHS 

PER YEAR 

(specify average) 1. LONG TERM 

AVERAGE 

2. MAXIMUM 

DAILY 

1. LONG TERM 

AVERAGE 

2. MAXIMUM 

DAILY 

C. DURATION 

(in days) 

 

III. PRODUCTION 

A. Does an effluent guideline limitation promulgated by EPA under Section 304 of the Clean Water Act apply to your facility? 

YES (complete Item III-B) NO (go to Section IV)

B. Are the limitations in the applicable effluent guideline expressed in terms of production (or other measure of operation)? 

YES (complete Item III-C) NO (go to Section IV)

C. If you answered “yes” to Item III-B, list the quantity which represents an actual measurement of your level of production, expressed in the terms and units used in the 

applicable effluent guideline, and indicate the affected outfalls. 

1. AVERAGE DAILY PRODUCTION

a. QUANTITY PER DAY b. UNITS OF MEASURE c. OPERATION, PRODUCT, MATERIAL, ETC. 

(specify) 

2. AFFECTED OUTFALLS 

 (list outfall numbers) 

 

IV. IMPROVEMENTS 

A. Are you now required by any Federal, State or local authority to meet any implementation schedule for the construction, upgrading or operations of wastewater 

treatment equipment or practices or any other environmental programs which may affect the discharges described in this application? This includes, but is not limited to, 

permit conditions, administrative or enforcement orders, enforcement compliance schedule letters, stipulations, court orders, and grant or loan conditions. 

YES (complete the following table) NO (go to Item IV-B)

1. IDENTIFICATION OF CONDITION, 2. AFFECTED OUTFALLS 4. FINAL COMPLIANCE DATE 

AGREEMENT, ETC. 

a. NO. b. SOURCE OF DISCHARGE

3. BRIEF DESCRIPTION OF PROJECT 

a. REQUIRED b. PROJECTED 

 

B. OPTIONAL: You may attach additional sheets describing any additional water pollution control programs (or other environmental projects which may affect your 

discharges) you now have underway or which you plan. Indicate whether each program is now underway or planned, and indicate your actual or planned schedules for 

construction. 

 MARK “X” IF DESCRIPTION OF ADDITIONAL CONTROL PROGRAMS IS ATTACHED

EPA Form 3510-2C (8-90) PAGE 2 of 4 CONTINUE ON PAGE 3 
CONTINUED FROM PAGE 2 

EPA I.D. NUMBER (copy from Item 1 of Form 1) 

V. INTAKE AND EFFLUENT CHARACTERISTICS 

A, B, & C: See instructions before proceeding – Complete one set of tables for each outfall – Annotate the outfall number in the space provided. 

 NOTE: Tables V-A, V-B, and V-C are included on separate sheets numbered V-1 through V-9. 

D. Use the space below to list any of the pollutants listed in Table 2c-3 of the instructions, which you know or have reason to believe is discharged or may be discharged 

from any outfall. For every pollutant you list, briefly describe the reasons you believe it to be present and report any analytical data in your possession. 

1. POLLUTANT 2. SOURCE 1. POLLUTANT 2. SOURCE 

 

VI. POTENTIAL DISCHARGES NOT COVERED BY ANALYSIS 

Is any pollutant listed in Item V-C a substance or a component of a substance which you currently use or manufacture as an intermediate or final product or byproduct? 

 YES (list all such pollutants below ) NO (go to Item VI-B)

EPA Form 3510-2C (8-90) PAGE 3 of 4 CONTINUE ON REVERSE 
CONTINUED FROM THE FRONT 

VII. BIOLOGICAL TOXICITY TESTING DATA 

Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on any of your discharges or on a receiving water in 

relation to your discharge within the last 3 years? 

 YES (identify the test(s) and describe their purposes below) NO (go to Section VIII) 

VIII. CONTRACT ANALYSIS INFORMATION 

Were any of the analyses reported in Item V performed by a contract laboratory or consulting firm? 

 YES (list the name, address, and telephone number of, and pollutants analyzed by, 

each such laboratory or firm below) 

 NO (go to Section IX) 

A. NAME B. ADDRESS C. TELEPHONE 

(area code & no.) 

D. POLLUTANTS ANALYZED 

(list)

 

IX. CERTIFICATION 

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that 

qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system or those persons 

directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there 

are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. 

A. NAME & OFFICIAL TITLE (type or print) B. PHONE NO. (area code & no.) 

C. SIGNATURE D. DATE SIGNED 

EPA Form 3510-2C (8-90) PAGE 4 of 4 
PLEASE PRINT OR TYPE IN THE UNSHADED AREAS ONLY. You may report some or all of this information 

on separate sheets (use the same format) instead of completing these pages. 

SEE INSTRUCTIONS. 

EPA I.D. NUMBER (copy from Item 1 of Form 1) 

V. INTAKE AND EFFLUENT CHARACTERISTICS (continued from page 3 of Form 2-C)PART A –You must provide the results of at least one analysis for every pollutant in this table. Complete one table for each outfall. See instructions for additional details. 

2. EFFLUENT 

3. UNITS 

(specify if blank)

a. MAXIMUM DAILY VALUE 

b. MAXIMUM 30 DAY VALUE 

(if available) 

c. LONG TERM AVRG. VALUE 

(if available) 

1. POLLUTANT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

C

a. Biochemical Oxygen Demand (BOD) b. Chemical Oxygen Demand (COD) c. Total Organic Carbon (TOC)d. Total Suspended Solids (TSS) e. Ammonia (as N) f. Flow 

VALUE VALUE VALUE V

g. Temperature (winter) 

VALUE VALUE VALUE 

°C 

V

h. Temperature (summer) 

VALUE VALUE VALUE 

°C 

V

i. pH 

MINIMUM MAXIMUM MINIMUM MAXIMUM 

STANDARD UNITS 

PART B – Mark “X” in column 2-a for each pollutant you know or have reason to believe is present. Mark “X” in column 2-b for each pollutant you believe to be absent. If you mark colum

directly, or indirectly but expressly, in an effluent limitations guideline, you must provide the results of at least one analysis for that pollutant. For other pollutants for wh

quantitative data or an explanation of their presence in your discharge. Complete one table for each outfall. See the instructions for additional details and requirements. 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE 

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. VALUE 

(if available) 

1. POLLUTANT 

AND 

CAS NO. 

(if available) 

a. 

BELIEVED 

PRESENT 

b. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

a. Bromide (24959-67-9) b. Chlorine, Total Residual c. Color d. Fecal Coliform e. Fluoride (16984-48-8) f. Nitrate-Nitrite (as N) EPA Form 3510-2C (8-90) PAGE V-1 
ITEM V-B CONTINUED FROM FRONT 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE 

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. VALUE 

(if available) 

1. POLLUTANT 

AND 

CAS NO. 

(if available) 

a. 

BELIEVED 

PRESENT 

b. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

g. Nitrogen, Total Organic (as N) h. Oil and Grease i. Phosphorus (as P), Total (7723-14-0) j. Radioactivity(1) Alpha, Total (2) Beta, Total (3) Radium, Total (4) Radium 226, Total k. Sulfate (as SO4) 

(14808-79-8) 

l. Sulfide  (as S) m. Sulfite (as SO3) 

(14265-45-3) 

n. Surfactants o. Aluminum, Total (7429-90-5) p. Barium, Total (7440-39-3) q. Boron, Total (7440-42-8) r. Cobalt, Total (7440-48-4) s. Iron, Total (7439-89-6) t. Magnesium, Total (7439-95-4) u. Molybdenum, Total (7439-98-7) v. Manganese, Total (7439-96-5) w. Tin, Total (7440-31-5) x. Titanium, Total (7440-32-6) EPA Form 3510-2C (8-90) PAGE V-2 
CONTINUED FROM PAGE 3 OF FORM 2-C 

EPA I.D. NUMBER (copy from Item 1 of Form 1) OUTFALL NUMBER 

PART C - If you are a primary industry and this outfall contains process wastewater, refer to Table 2c-2 in the instructions to determine which of the GC/MS fractions you must test for

fractions that apply to your industry and for ALL toxic metals, cyanides, and total phenols. If you are not required to mark column 2-a (secondary industries, nonprocess w

fractions), mark “X” in column 2-b for each pollutant you know or have reason to believe is present. Mark “X” in column 2-c for each pollutant you believe is absent. If you 

provide the results of at least one analysis for that pollutant. If you mark column 2b for any pollutant, you must provide the results of at least one analysis for that pollutant if 

discharged in concentrations of 10 ppb or greater. If you mark column 2b for acrolein, acrylonitrile, 2,4 dinitrophenol, or 2-methyl-4, 6 dinitrophenol, you must provide the resu

pollutants which you know or have reason to believe that you discharge in concentrations of 100 ppb or greater. Otherwise, for pollutants for which you mark column 2b, yobriefly describe the reasons the pollutant is expected to be discharged. Note that there are 7 pages to this part; please review each carefully. Complete one table (all 7 

additional details and requirements. 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. 

VALUE (if available) 

1. POLLUTANT 

AND 

CAS NUMBER 

(if available) 

a. 

TESTING 

REQUIRED 

b. 

BELIEVED 

PRESENT 

c. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

METALS, CYANIDE, AND TOTAL PHENOLS 1M. Antimony, Total (7440-36-0) 2M. Arsenic, Total (7440-38-2) 3M. Beryllium, Total (7440-41-7) 4M. Cadmium, Total (7440-43-9) 5M. Chromium, Total (7440-47-3) 6M. Copper, Total (7440-50-8) 7M. Lead, Total (7439-92-1) 8M. Mercury, Total (7439-97-6) 9M. Nickel, Total (7440-02-0) 10M. Selenium, Total (7782-49-2) 11M. Silver, Total (7440-22-4) 12M. Thallium, Total (7440-28-0) 13M. Zinc, Total (7440-66-6) 14M. Cyanide, Total (57-12-5) 15M. Phenols, Total DIOXIN 2,3,7,8-Tetrachlorodibenzo-PDioxin (1764-01-6) DESCRIBE RESULTS EPA Form 3510-2C (8-90) PAGE V-3 
CONTINUED FROM THE FRONT 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. 

VALUE (if available) 

1. POLLUTANT 

AND 

CAS NUMBER 

(if available) 

a. 

TESTING 

REQUIRED 

b. 

BELIEVED 

PRESENT 

c. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

GC/MS FRACTION – VOLATILE COMPOUNDS 1V. Accrolein (107-02-8) 2V. Acrylonitrile (107-13-1) 3V. Benzene (71-43-2) 4V. Bis (Chloromethyl) Ether (542-88-1) 5V. Bromoform (75-25-2) 6V. Carbon Tetrachloride (56-23-5) 7V. Chlorobenzene (108-90-7) 8V. Chlorodibromomethane (124-48-1) 9V. Chloroethane (75-00-3) 10V. 2-Chloroethylvinyl Ether (110-75-8) 11V. Chloroform (67-66-3) 12V. Dichlorobromomethane (75-27-4) 13V. Dichlorodifluoromethane (75-71-8) 14V. 1,1-Dichloroethane (75-34-3) 15V. 1,2-Dichloroethane (107-06-2) 16V. 1,1-Dichloroethylene (75-35-4) 17V. 1,2-Dichloropropane (78-87-5) 18V. 1,3-Dichloropropylene (542-75-6) 19V. Ethylbenzene (100-41-4) 20V. Methyl Bromide (74-83-9) 21V. Methyl Chloride (74-87-3) EPA Form 3510-2C (8-90) PAGE V-4 
CONTINUED FROM PAGE V-4 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. 

VALUE (if available) 

1. POLLUTANT 

AND 

CAS NUMBER

(if available) 

a. 

TESTING 

REQUIRED 

b. 

BELIEVED 

PRESENT 

c. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

GC/MS FRACTION – VOLATILE COMPOUNDS (continued) 22V. Methylene Chloride (75-09-2) 23V. 1,1,2,2-Tetrachloroethane (79-34-5) 24V. Tetrachloroethylene (127-18-4) 25V. Toluene (108-88-3) 26V. 1,2-TransDichloroethylene (156-60-5) 27V. 1,1,1-Trichloroethane (71-55-6) 28V. 1,1,2-Trichloroethane (79-00-5) 29V Trichloroethylene (79-01-6) 30V. Trichlorofluoromethane (75-69-4) 31V. Vinyl Chloride (75-01-4) GC/MS FRACTION – ACID COMPOUNDS 1A. 2-Chlorophenol (95-57-8) 2A. 2,4-Dichlorophenol (120-83-2) 3A. 2,4-Dimethylphenol (105-67-9) 4A. 4,6-Dinitro-OCresol (534-52-1) 5A. 2,4-Dinitrophenol (51-28-5) 6A. 2-Nitrophenol (88-75-5) 7A. 4-Nitrophenol (100-02-7) 8A. P-Chloro-MCresol (59-50-7) 9A. Pentachlorophenol (87-86-5)10A. Phenol (108-95-2) 11A. 2,4,6-Trichlorophenol (88-05-2) 

EPA Form 3510-2C (8-90) PAGE V-5 
CONTINUED FROM THE FRONT 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. 

VALUE (if available) 

1. POLLUTANT 

AND 

CAS NUMBER 

(if available) 

a. 

TESTING 

REQUIRED 

b. 

BELIEVED 

PRESENT 

c. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

GC/MS FRACTION – BASE/NEUTRAL COMPOUNDS 1B. Acenaphthene (83-32-9) 2B. Acenaphtylene (208-96-8) 3B. Anthracene (120-12-7) 4B. Benzidine (92-87-5) 5B. Benzo (a) Anthracene (56-55-3) 6B. Benzo (a) Pyrene (50-32-8) 7B. 3,4-Benzofluoranthene (205-99-2) 8B. Benzo (ghi) 

Perylene (191-24-2) 

9B. Benzo (k) 

Fluoranthene (207-08-9) 

10B. Bis (2-Chloroethoxy) Methane (111-91-1) 11B. Bis (2-Chloroethyl) Ether (111-44-4) 12B. Bis (2-

Chloroisopropyl) Ether (102-80-1) 

13B. Bis (2-Ethylhexyl) Phthalate (117-81-7) 14B. 4-Bromophenyl Phenyl Ether (101-55-3) 15B. Butyl Benzyl Phthalate (85-68-7) 16B. 2-Chloronaphthalene (91-58-7) 17B. 4-Chlorophenyl Phenyl Ether (7005-72-3) 18B. Chrysene (218-01-9) 19B. Dibenzo (a,h) Anthracene (53-70-3) 20B. 1,2-Dichlorobenzene (95-50-1) 21B. 1,3-Di-chlorobenzene (541-73-1) EPA Form 3510-2C (8-90) PAGE V-6 
CONTINUED FROM PAGE V-6 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. 

VALUE (if available) 

1. POLLUTANT 

AND 

CAS NUMBER 

(if available) 

a. 

TESTING 

REQUIRED 

b. 

BELIEVED 

PRESENT 

c. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

GC/MS FRACTION – BASE/NEUTRAL COMPOUNDS (continued) 

22B. 1,4-Dichlorobenzene (106-46-7) 23B. 3,3-Dichlorobenzidine (91-94-1) 24B. Diethyl Phthalate (84-66-2) 25B. Dimethyl Phthalate (131 -11-3) 26B. Di-N-Butyl Phthalate (84-74-2) 27B. 2,4-Dinitrotoluene (121-14-2) 28B. 2,6-Dinitrotoluene (606-20-2) 29B. Di-N-Octyl Phthalate (117-84-0) 30B. 1,2-Diphenylhydrazine (as Azobenzene) (122-66-7) 31B. Fluoranthene (206-44-0) 32B. Fluorene (86-73-7) 33B. Hexachlorobenzene (118-74-1) 34B. Hexachlorobutadiene (87-68-3) 35B. Hexachlorocyclopentadiene (77-47-4) 36B Hexachloroethane (67-72-1) 37B. Indeno (1,2,3-cd) Pyrene 

(193-39-5) 

38B. Isophorone (78-59-1) 39B. Naphthalene (91-20-3) 40B. Nitrobenzene (98-95-3) 41B. N-Nitrosodimethylamine (62-75-9) 42B. N-NitrosodiN-Propylamine (621-64-7) EPA Form 3510-2C (8-90) PAGE V-7 
CONTINUED FROM THE FRONT 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. 

VALUE (if available) 

1. POLLUTANT 

AND 

CAS NUMBER 

(if available) 

a. 

TESTING 

REQUIRED 

b. 

BELIEVED 

PRESENT 

c. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

GC/MS FRACTION – BASE/NEUTRAL COMPOUNDS (continued) 43B. N-Nitrosodiphenylamine (86-30-6) 44B. Phenanthrene (85-01-8) 45B. Pyrene (129-00-0) 46B. 1,2,4-Trichlorobenzene (120-82-1) 

GC/MS FRACTION – PESTICIDES 

1P. Aldrin (309-00-2) 2P. α-BHC (319-84-6) 3P. β-BHC (319-85-7) 4P. γ-BHC  (58-89-9) 5P. δ-BHC (319-86-8) 6P. Chlordane (57-74-9) 7P. 4,4’-DDT (50-29-3) 8P. 4,4’-DDE (72-55-9) 9P. 4,4’-DDD (72-54-8) 10P. Dieldrin (60-57-1) 11P. α-Enosulfan (115-29-7) 12P. β-Endosulfan 

(115-29-7) 

13P. Endosulfan Sulfate  (1031-07-8) 14P. Endrin (72-20-8) 15P. Endrin Aldehyde (7421-93-4) 16P. Heptachlor (76-44-8) EPA Form 3510-2C (8-90) PAGE V-8 
CONTINUED FROM PAGE V-8 

EPA I.D. NUMBER (copy from Item 1 of Form 1) OUTFALL NUMBER 

2. MARK “X” 3. EFFLUENT 4. UNITS 

a. MAXIMUM DAILY VALUE

b. MAXIMUM 30 DAY VALUE 

(if available)

c. LONG TERM AVRG. 

VALUE (if available) 

1. POLLUTANT 

AND 

CAS NUMBER 

(if available) 

a. 

TESTING 

REQUIRED 

b. 

BELIEVED 

PRESENT 

c. 

BELIEVED 

ABSENT (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASS d. NO. OF ANALYSES a. CONCEN- TRATION b. MASS 

GC/MS FRACTION – PESTICIDES (continued) 17P. Heptachlor Epoxide (1024-57-3) 18P. PCB-1242  (53469-21-9) 19P. PCB-1254 (11097-69-1) 20P. PCB-1221 (11104-28-2) 21P. PCB-1232 (11141-16-5) 22P. PCB-1248 (12672-29-6) 23P. PCB-1260 (11096-82-5) 24P. PCB-1016  (12674-11-2) 25P. Toxaphene (8001-35-2) EPA Form 3510-2C (8-90) PAGE V-9 
Disclaimer 

This is an updated PDF document that allows you to type your information 

directly into the form, print it, and save the completed form. 

Note: This form can be viewed and saved only using Adobe Acrobat Reader 

version 7.0 or higher, or if you have the full Adobe Professional version. 

Instructions: 

1. Type in your information 

2. Save file (if desired) 

3. Print the completed form 

4. Sign and date the printed copy 

5. Mail it to the directed contact. 
United States 

Environmental Protection 

Agency 

Office of Water 

Enforcement and Permits 

Washington, DC 20460 

EPA Form 3510-2D 

August 1990 

Permits Division 

Application Form 2D — 

New Sources and 

New Dischargers: 

Application for Permit to 

Discharge Process 

Wastewater 
PAPERWORK REDUCTION ACT NOTICE: The public reporting and 

recordkeeping burden for this collection of information is estimated to average 

32 hours as an average response for some minor facilities, to 46 hours as an 

average per response for some major facilities, with a weighted average for 

major and minor of 33.2 hours per response. This estimate includes the time 

needed to review instructions; develop, acquire, install, and utilize validating, 

and verifying information, processing and maintaining information, and 

disclosing and providing information; adjust the existing ways to comply with 

any previously applicable instructions and requirements; train personnel to 

respond to a collection of information; search existing data sources; complete 

and review the collection of information; and transmit or otherwise disclose the 

information. As specified in 5 CFR 1320.5(b) (2), an Agency may not conduct 

or sponsor, and a person is not required to respond to a collection of 

information unless it displays a currently valid OMB control number. 

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

collection of information, including suggestions for reducing the burden, to 

Chief, OPPE Regulatory Information Division, U.S. Environmental Protection 

Agency 1200 Pennsylvania Ave., NW, Washington, DC 20460; and to the 

Office of Information and Regulatory Affairs, Office of Management and 

Budget, 725 17th St., NW, Washington, DC 20503, Attention: Desk Officer for 

EPA. Include the OMB control number in any correspondence. Do not send 

the completed application form to these addresses. 

EPA Form 3510-2D (Rev. 8-90) 
Form 2D Instructions 

EPA Form 3510-2D (Rev. 8-90) I-1

Form 2D must be completed in conjunction with EPA form 3510-1 

(Form 1). 

This form must be completed by applicants who checked “yes” to 

Item II-D in Application Form 1. However, facilities which discharge 

only nonprocess wastewater that is not regulated by an effluent 

limitations guideline or new source performance standard may use 

EPA Form 3510-2E (Form 2E). Educational, medical, and 

commercial chemical laboratories should use this form or EPA Form 

3510-2C (Form 2C). To further determine if you are a new source or 

a new discharger, see §122.2 and §122.29. This form should not be 

used for discharges of stormwater runoff. 

Public Availability of Submitted Information. 

You may not claim as confidential any information required by this 

form or Form 1, whether the information is reported on the forms or 

in an attachment, Section 402(j) of the CWA requires that all permit 

applications shall be available to the public. This information will 

therefore be made available to the public upon request. 

You may not claim as confidential any information you submit to EPA 

which goes beyond that required by this form and Form 1. 

Confidentiality claims for effluent data must be denied. If you do not 

assert a claim of confidentiality at the time of submitting the 

information, EPA may make the information public without further 

notice. Claims of confidentiality will be handled in accordance with 

EPA’s business confidentiality regulations in 40 CFR Part 2. 

Completeness 

Your application will not be considered complete unless you answer 

every question on this form and on Form 1 (except as instructed 

below). If an items does not apply to you, enter “NA” (for “not 

applicable”) to show that you considered the question. 

Followup Requirements 

Although you are now required to submit estimated data on this form 

(Form 2D), please note that no later than two years after you begin 

discharging from the proposed facility, you must complete and 

submit Items V and VI of NPDES application Form 2C (EPA Form 

3510-2C). However, you need not complete those portions of Item V 

requiring tests which you have already performed under the 

discharge monitoring requirements of your NPDES permit. In 

addition, the permitting authority may waive requirements of Items VA and VI if the permittee makes the demonstrations required under 

40 CFR §122.22(g)(7)(i)(B) and 122.21(g)(9). 

Definitions 

All significant terms used in these instructions and in the form are 

defined in the glossary found in the General Instructions which 

accompany Form 1. 

Item I 

You may use the map you provided for Item XI of Form 1 to 

determine the latitude and longitude (to the nearest 15 seconds) of 

each of your outfalls and the name of the receiving water. You 

should name all waters to which discharge is made and which flow 

into significant receiving waters. For example, if the discharge is 

made to a ditch which flows into an unnamed tributary which in turn 

flows into a named river, you should provide the name or description 

(if no name is available) of the ditch, the tributary, and the river. 

Item II 

This item requires your best estimate of the date on which your 

facility or new outfall will begin to discharge. 

Item III-A 

List all outfalls, their source (operations contributing to the flow), and 

estimate an average flow from each source. Briefly describe the 

planned treatment for these wastewaters prior to discharge. Also 

describe the ultimate disposal of any solid or liquid wastes not 

discharged. You should describe the treatment in either a narrative 

form or list the proper code for the treatment unit from a list provided 

in Table 2D-1. 

Item III-B 

An example of an acceptable line drawing appears in Figure 2D-1 to 

these instructions. The line drawing should show the route taken by 

water in your proposed facility form intake to discharge. Show all 

sources of wastewater, including process and production areas, 

sanitary flows, cooling water, and storm water runoff. You may group 

similar operations into a single unit, labeled to correspond to the 

more detailed listing in Item III-A. The water balance should show 

estimates of anticipated average flows. Show all significant losses of 

water to production, atmosphere, and discharge. You should use 

your best estimates. 

Item III-C 

Fill in every applicable column in this item for each source of 

intermittent or seasonal discharge. Base your answers on your best 

estimate. A discharge is intermittent if it occurs with interruptions 

during the operating hours of the facility. Discharges caused by 

routine maintenance shutdowns, process changes, or other similar 

activities are not considered to be intermittent. A discharge is 

seasonal if it occurs only during certain parts of the year. The 

reported flow rate is the highest daily value and should be measured 

in gallons per day. Maximum total volume means the total volume of 

any one discharge within 24 hours and is measured in units such as 

gallons. 

Item IV 

“Production” in this question refers to those goods which the 

proposed facility will produce, not to “wastewater” production. This 

information is only necessary where production-based new source 

performance standards (NSPS) or effluent guidelines apply to your 

facility. Your estimated production figures should be based on a 

realistic projection of actual daily production level (not design 

capacity) for each of the first three operating years of the facility. This 

estimate must be a long-term-average estimate (e.g., average 

production on an annual basis). If production will vary depending on 

long-term shifts in operating schedule or capacity, the applicant may 

report alternative production estimates and the basis for the alternate 

estimates. 

If known, report quantities in the units of measurement used in the 

applicable NSPS or effluent guideline. For example, if the applicable 

NSPS is expressed as “grams of pollutant discharged per kilogram of 

unit production,” then report maximum “Quantity Per Day” in 

kilograms. If you do not know whether any NPSP or effluent 

guideline applies to your facility, report quantities in any unit of 

measurement known to you. If an effluent guideline or NSPS 

specifies a method for estimating production, that method must be 

followed. 

There is no need to conduct new studies to obtain these figures; only 

data already on hand are required. You are not required to indicate 

how the reported information was calculated. 

Item V-A, B, and C 

These items require you to estimate and report data on the pollutants 

expected to be discharged from each of your outfalls. Where there is 

more than one outfall, you should submit a separate Item V for each 

outfall. For Part C only a list is required. Sampling and analysis are 

not required at this time. If, however, data from such analyses are 

available, then those data should be reported. Each part of this item 

addresses a different set of pollutants or parameters and must be 

completed in accordance with the specific instructions for that part. 

The following are the general and specific instructions for Items V-A 

through V-C. 

Item V – General Instructions 

Each part of this item requires you to provide an estimated maximum 

daily and average daily value for each pollutant or parameter listed 

(see Table 2D-2), according to the specific instructions below. The 

source of the data is also required. 

For Parts A through C, base your determination of whether a 

pollutant will be present in your discharge on your knowledge of the 

proposed facility’s raw materials, maintenance chemicals, 
EPA Form 3510-2D (Rev. 8-90) I-2

intermediate and final products, byproducts, and any analyses of 

your effluent or of any similar effluent. You may also provide the 

determination and the estimates based on available in-house or 

contractor’s engineering reports or any other studies performed on 

the proposed facility (see Item VI of the form). If you expect a 

pollutant to be present solely as a result of its presence in your 

intake water, please state this information on the form. 

Please note that no later than 2 years after you begin discharging 

from the proposed facility, you must complete and submit Items V 

and VI of NPDES application Form 2C (followup data). 

Reporting Intake Data. You are not required to report pollutants or 

parameters present in intake water unless you wish to demonstrate 

your eligibility for a “net” effluent limitation for these pollutants or 

parameters, that is, an effluent limitation adjusted to provide 

allowance for the pollutants or parameters present in your intake 

water. If you wish to obtain credits for pollutants or parameters 

present in your intake water, please insert a separate sheet, with a 

short statement of why you believe you are eligible (see §122.45(g)), 

under Item VII (Other Information). You will then be contacted by the 

permitting authority for further instructions. 

All estimated pollutant or parameter levels must be reported as 

concentration and as total mass, except for discharge flow, 

temperature, and pH. Total mass is the total weight of pollutants or 

parameters discharged over a day. 

Use the following abbreviations for units: 

Concentration Mass 

ppm................. parts per million lbs................................. pounds 

mg/l .............milligrams per liter ton .............. tons (English tons) 

ppb................... parts per billion mg ............................milligrams 

ug/l............ micrograms per liter g .....................................grams 

kg.............................. kilograms T ............... tonnes (metric tons) 

Source 

In providing the estimates, use the codes in the following table to 

indicate the source of such information in column 4 of Parts V – A 

and – B. 

Code 

Engineering study ..................................................................... 1 

Actual data from pilot plants...................................................... 1 

Estimates from other engineering studies................................. 2 

Data from other similar plants................................................... 3 

Best professional estimates...................................................... 4 

Others ...........................................................specify on the form 

Item V-A 

Estimates of data on pollutants or parameters in Group A must be 

reported by all applicants for all outfalls: including outfalls containing 

only noncontact cooling water or nonprocess wastewater. 

To request a waiver from reporting any of these pollutants or 

parameters, the applicant must submit to the permitting authority a 

written request specifying which pollutants or parameters should be 

waived and the reasons for requesting such a waiver. This request 

should be submitted to the permitting authority before or with the 

permit application. The permitting authority may waive the 

requirements for information about these pollutants or parameters if 

he or she determines that less stringent reporting requirements are 

adequate to support issuance of the permit. No extensive 

documentation will normally be needed, but the applicant should 

contact the permitting authority if she or he wishes to receive 

instructions on what his or her particular request should contain. 

Item V-B 

Estimates of data on pollutants in Group B must be reported by all 

applicants for all outfalls, including outfalls containing only 

noncontact cooling water or nonprocess wastewater. You are merely 

required to report estimates for those pollutants which you know or 

have reason to believe will be discharged or which are limited 

directly by an effluent limitations guideline (or NSPS) or indirectly 

through promulgated limitations on an indicator pollutant. The priority 

pollutants in Group B are divided into the following three sections: 

1) Metal toxic pollutants, total cyanide, and total phenols 

2) 2,3,7,8-Tetrachlorodibenzo-P-Dioxin (TCDD) (CAS # 1764-016) 

3) Organic Toxic Pollutants (Gas Chromatography/Mass Spectrometry Fractions) 

 a) Volatile compounds 

 b) Acid compounds 

 c) Base/neutral compounds 

 d) Pesticides 

For pollutants listed in Sections 1 and 3, you must report estimates 

as instructed above: 

For Section 2, you are required to report that TCDD may be 

discharged if you will use or manufacture one of the following 

compounds, or if you know or have reason to believe that TCDD is or 

may be present in an effluent: 

A. 2,4,5-trichlorophenoxy acetic acid (2,4,5-T) (CAS # 93-765); 

B. 2-(2,4,5-trichlorophenoxy) propanoic acid (Silvex, 2,4, 5TP) (CAS 

# 93-72-1); 

C. 2-(2,4,5-trichlorophenoxy) ethyl 2,2-dichloropropionate (Erbon) 

(CAS # 136-25-4); 

D. 0, O-dimethyl 0-(2,4,5-trichlorophenyl) phosphorothioate 

(Ronnel) (CAS # 299-84-3); 

E. 2,4,5-trichlorophenol (TCP) (CAS # 95-95-4); or 

F. Hexachlorophene (HCP) (CAS # 70-30-4). 

Small Business Exemption 

If you are a “small business,” you are exempt from the reporting 

requirement for Item V-B (section 3). You may qualify as a “small 

business” if you it one of the following definitions: 

1) Your expected gross sales will total less than $100,000 per year 

for the next three years, or 

2) In the case of coal mines, you average production will be less 

than 100,000 tons of coal per year. 

If you are a “small business,” you may submit projected sales or 

production figures to qualify for this exemption. The sales or 

production figures you submit must be for the facility which is the 

source of the discharge. The data should not be limited only to 

production or sales for the process or processes which contribute to 

the discharge, unless those are the only processes at your facility. 

For sales data, where intracorporate transfers of goods and services 

are involved, the transfer price per unit should approximate market 

prices for those goods and services as closely as possible. If 

necessary, you may index your sales figures to the second quarter of 

1980 to demonstrate your eligibility for a small business exemption. 

This may be done by using the gross national product price deflator 

(second quarter of 1980 = 100), an index available in “National 

Income and Product Accounts of the United States” (Department of 

Commerce, Bureau of Economic Analysis). 

The small business exemption applies to the GC/MS fractions 

(Section 3) of Item V-B only. Even if you are eligible for a small 

business exemption, you are still required to provide information on 

metals, cyanide, total phenols, and dioxin in Item V-B, as well as all 

of Items V-A and C. 

Item V-C 

List any pollutants in Table 2D-3 that you believe to be present in 

any outfalls and briefly explain why you believe they will be present. 

No estimate of the pollutant’s quantity is required, unless you already 

have quantitative data. 

Note: The discharge of pollutants listed in Table 2D-4 may subject 

you to the additional requirements of section 311 of the CWA (Oil 

and Hazardous Substance Liability). These requirements are not 

administered through the NPDES program. However, if you wish an 

exemption under 40 CFR 117.12(a)(2) from these requirements, 

attach additional sheets of paper to this form providing the following 

information: 
EPA Form 3510-2D (Rev. 8-90) I-3

A. The substance and the amount of each substance which may be 

discharged; 

B. The origin and source of the discharge of the substance; 

C. The treatment which is to be provided for the discharge by: 

1. An onsite treatment system separate from any treatment 

system which will treat your normal discharge; 

2. A treatment system designed to treat your normal discharge 

and which is additionally capable of treating the amount of the 

substance identified under paragraph 1 above; or 

3. Any combination of the above. 

An exemption from the section 311 reporting requirements pursuant 

to 40 CFR Part 117 for pollutants on Table 2D does not exempt you 

from the section 402 reporting requirements pursuant to 40 CFR Part 

122 (Item V-C) for pollutants listed on Table 2D-3. 

For further information on exclusions from Section 311, see 40 CFR 

Section 117.12(a)(2) and (c), or contact your EPA Regional office 

(Table 1 in Form 1 instructions). 

Item VI-A 

If an engineering study was conducted, check the box labeled “report 

available.” If no study was done, check the box labeled “no report.” 

Item VI-B 

Report the name and location of any existing plant(s) which (to the 

best of your knowledge) resembles your planned operation with 

respect to items produced, production process, wastewater 

constituents, or wastewater treatment. No studies need be 

conducted to respond to this item. Only data which are already 

available need be submitted. 

This information will be used to inform the permit writer of 

appropriate treatment methods and their associated permit 

conditions and limits. 

Item VII 

A space is provided for additional information which you believe 

would be useful in setting permit limits, such as additional sampling. 

Any response is optional. 

Item VIII 

The Clean Water Act provides for severe penalties for submitting 

false information on this application form. 

Section 309(c)(2) of the Clean Water Act provides that “Any person 

who knowingly makes any false statement, representation, or 

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

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

than six months, or both.” 

40 CFR Part 122.22 Requires the Certification to be Signed as 

Follows: 

A. For a corporation: by a responsible corporate officer. 

 A responsible corporate officer means (i) a president, secretary, 

treasurer, or vice-president of the corporation in charge of a 

principal business function, or any other person who performs 

similar policy or decision-making functions for the corporation, or 

(ii) the manager of one or more manufacturing, production or 

operating facilities employing more than 250 persons or having 

gross annual sales or expenditures exceeding $25,000,000 (in 

second-quarter 1980 dollars), if authority to sign documents has 

been assigned or delegated to the manager in accordance with 

corporate procedures. 

B. For a partnership or sole proprietorship: by a general partner or 

the proprietor, respectively; or 

C. For a municipality, State, Federal, or other public agency: by 

either a principal executive officer or ranking elected official. For 

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

agency includes (i) the chief executive officer of the agency, or 

(ii) a senior executive office having responsibility for the overall 

operations of the principal geographic unit of the agency (e.g., 

Regional Administrators of EPA). 
EPA Form 3510-2D (Rev. 8-90) 

Table 2D-1 

PHYSICAL TREATMENT PROCESSES 

1–A. . . . . . . . . . Ammonia Stripping 1–M . . . . . . . . . . Grit Removal 

1–B . . . . . . . . . . Dialysis 1–N . . . . . . . . . . Microstraining 

1–C . . . . . . . . . . Diatomaceous Earth Filtration 1–O . . . . . . . . . . Mixing 

1–D . . . . . . . . . . Distillation 1–P . . . . . . . . . . . Moving Bed Filters 

1–E . . . . . . . . . Electrodialysis 1–Q. . . . . . . . . . . Multimedia Filtration 

1–F . . . . . . . . . Evaporation 1–R . . . . . . . . . . Rapid Sand Filtration 

1–G . . . . . . . . . . Flocculation 1–S . . . . . . . . . . . Reverse Osmosis (Hyperfiltration) 

1–H . . . . . . . . . . Flotation 1–T . . . . . . . . . . . Screening 

1–I . . . . . . . . . . Foam Fractionation 1–U . . . . . . . . . . Sedimentation (Settling) 

1–J . . . . . . . . . . Freezing 1–V . . . . . . . . . . . Slow Sand Filtration 

1–K . . . . . . . . . . Gas–Phase Separation 1–W . . . . . . . . . . Solvent Extraction 

1–L . . . . . . . . . . Grinding (Comminutors) 1–X . . . . . . . . . . . Sorption 

CHEMICAL TREATMENT PROCESSES 

2–A . . . . . . . . . . Carbon Adsorption 2–G . . . . . . . . . . Disinfection (Ozone) 

2–B . . . . . . . . . . Chemical Oxidation 2–H . . . . . . . . . . Disinfection (Other) 

2–C . . . . . . . . . . Chemical Precipitation 2–I . . . . . . . . . . . Electrochemical Treatment 

2–D . . . . . . . . . . Coagulation 2–J . . . . . . . . . . . Ion Exchange 

2–E . . . . . . . . . . Dechlorination 2–K . . . . . . . . . . . Neutralization 

2–F . . . . . . . . . . Disinfection (Chlor ine) 2–L . . . . . . . . . . . Reduction 

BIOLOGICAL TREATMENT PROCESSES 

3–A . . . . . . . . . . Activated Sludge 3–E . . . . . . . . . . . Pre-Aeration 

3–B . . . . . . . . . . Aerated Lagoons 3–F . . . . . . . . . . . Spray Irrigation/Land Application 

3–C . . . . . . . . . . Anaerobic Treatment 3–G . . . . . . . . . . Stabilization Ponds 

3–D . . . . . . . . . . Nitrification–Denitrification 3–H . . . . . . . . . . Trickling Filtration 

OTHER PROCESSES 

4–A . . . . . . . . . . Discharge to Surface Water 4–C . . . . . . . . . . Reuse/Recycle of Treated Effluent 

4–B . . . . . . . . . . Ocean Discharge Through Outfall 4-D . . . . . . . . . . . Underground Injection 

SLUDGE TREATMENT AND DISPOSAL PROCESSES 

5–A . . . . . . . . . . Aerobic Digestion 5–M . . . . . . . . . . Heat Drying 

5–B . . . . . . . . . . Anaerobic Digestion 5–N . . . . . . . . . . Heat Treatment 

5–C. . . . . . . . . . Belt Filtration 5–O . . . . . . . . . . Incineration 

5–D. . . . . . . . . . Centrifugation 5–P . . . . . . . . . . . Land Application 

5–E . . . . . . . . . . Chemical Conditioning 5–Q . . . . . . . . . . Landfill 

5–F . . . . . . . . . . Chlorine Treatment 5–R . . . . . . . . . . Pressure Filtration 

5–G . . . . . . . . . . Composting 5–S . . . . . . . . . . Pyrolysis 

5–H . . . . . . . . . . Drying Beds 5–T . . . . . . . . . . Sludge Lagoons 

5–I. . . . . . . . . . . Elutriation 5–U . . . . . . . . . . Vacuum Filtration 

5–J . . . . . . . . . . Flotation Thickening 5–V . . . . . . . . . . Vibration 

5–K . . . . . . . . . . Freezing 5–W . . . . . . . . . . Wet Oxidation 

5–L . . . . . . . . . . Gravity Thickening 
EPA Form 3510-2D (Rev. 8-90) 

Table 2D-2 

GROUP A 

Biochemical Oxygen Demand (BOD) Ammonia (as N) 

Chemical Oxygen Demand (COD) Temperature (winter) 

Total Organic Carbon (TOC) Temperature (summer) 

Total Suspended Solids (TSS) pH 

Flow 

GROUP B 

Bromide Sulfate (as S04) 

Total Residual Chlorine Sulfide (as S) 

Color Sulfite (as S03) 

Fecal Coliform Surfactants 

Fluoride Aluminum, Total 

Nitrate-Nitrite (as N) Barium, Total 

Oil and Grease Boron, Total 

Phosphorus (as P) Total Cobalt, Total 

Radioactivity Iron, Total 

(1) Alpha, Total Magnesium, Total 

(2) Beta, Total Molybdenum, Total 

(3) Radium, Total Manganese, Total 

(4) Radium 226, Total Tin, Total 

 Titanium, Total 

Section 1 

Antimony, Total Arsenic, Total 

Beryllium, Total Cadmium, Total 

Chromium, Total Copper, Total 

Lead, Total Mercury, Total 

Nickel, Total Selenium, Total 

Silver, Total Thallium, Total 

Zinc, Total Cyanide, Total 

Phenols, Total 

Section 2 

2,3,7,8,Tetrachlorodibenzo-P-Dioxin 

Section 3 

GC/MS FRACTION* — VOLATILE COMPOUNDS 

Acrolein Vinyl Chloride 

Benzene Acrylonitirle 

Carbon Tetrachloride Bromoform 

Chlorodibramomethane Chlorobenzene 

2-Chloroethylvinyl Ether Chloroethane 

Dichlorobomomethane Chloroform 

1,2-Dichloroethane 1,1-Dichloroethane 

1,2-Dichloropropane 1,3-Dichloropropylene 

Ethylbenzene Methyl Bromide 

Methyl Chloride Methylene chloroethane 

1,1,2,2-Tetrachloroethane Tetrachloroethylene 

Toluene 1,2-Trans-Dichloroethylene 

1,1,1-Trichloroethane 1,1,2-Trichloroethane 

Trichloroethylene 

GS/MS FRACTION — ACID COMPOUNDS 

2-Chlorophenol 2,4-Dichlorophenol 

2,4-Dimethylphenol 4,6-Dinitro-O-Cresol 

2,4-Dinitro-phenol 2-Nitrophenol 

4-Nitrophenol P-Chloro-M-Cresol 

Pentachlorophenol Phenol 

2,4,6-Trichlorophenol 
EPA Form 3510-2D (Rev. 8-90) 

Table 2D-2 

GC/MS FRACTION — BASE/NEUTRAL COMPOUNDS 

Acenaphthene Acenaphtylene 

Anthracene Benzidine 

Benzo (a) Anthracene Benzo (a) Pyrene 

3,5-Benzofluoranthene Benzo (ghi) Perylene 

Benzo (k) Fluoranthene Bis (2 Chloroethoxy) Methane 

Bis (2-Chloroethyl) Ether Bis (2-Chloroisopropyl) Ether 

Bis (2-Ethylhexyl) Phthalate 4-Bromophenyl Phenyl Ether 

Butyl Benzyl Phthalate 2-Chloronaphthalene 

4-Chlorophenyl Phenyl Ether Chrysene 

Dibenzo (a, h) Anthracene 1,2-Dichlorobenzene 

1,3-Dichlorobenzene 1,4-Dichlorobenzene 

3,3-Dichlorobenzidine Diethyl Phthalate 

Dimethyl Phthalate Di-N-Butyl Phthalate 

2,4-Dinitrotoluene 2,6-Dinitrotoluene 

Di-N-Octyl Phthalate 1,2, Diphenylhydrazine (as Azobenzen) 

Fluoranthene Fluorene 

Hexachlorobenzene Hexachlorobutadiene 

Hexachlorocyclopentadiene Hexachloroethane 

Indeno (1,2,3-cd) Pyrene lsophorone 

Naphthalene Nitrobenzene 

N-Nitro-sodimethylamine N-Nitrosodi-N-Propylamine 

N-Nitro-sodiphenylamine Phenanthrene 

Pyrene 1,2,4-Trichlorobenzene 

GC/MS FRACTION — PESTICIDES 

Aldrin Gamma-BHC 

Alpha-BHC Delta-BHC 

Beta-BHC Chlordane 

4,4' DDT 4,4' DDE 

4,4'-DDD Dieldrin 

Alpha-Endosulfan Beta-Endosulfan 

Endosulfan Sulfate Endrin 

Endrin Aldehyde Heptachlor 

Heptachlor Epoxide PCB-1242 

PCB-1254 PCB-1221 

PCB-1232 PCB-1248 

PCB-1260 PCB-1016 

Toxaphene 

*fractions defined in 40 CFR Part 136 
TOXIC POLLUTANTS AND HAZARDOUS SUBSTANCES 

REQUIRED TO BE IDENTIFIED BY APPLICANTS IF EXPECTED TO BE PRESENT 

EPA Form 3510-2D (Rev. 8-90) 

Table 2D-3

TOXIC POLLUTANT HAZARDOUS SUBSTANCES 

Asbestos Isoprene 

Isopropanolamine dodecylbenzenesulfonate 

HAZARDOUS SUBSTANCES Kelthane 

Kepone 

Acetaldehyde Malathion 

Allyl alcohol Mercaptodimethur 

Allyl chloride Methoxychlor 

Amyl acetate Methyl mercaptan 

Aniline Methyl methacrylate 

Benzonitrile Methyl parathion 

Benzyl chloride Mevinphos 

Butyl acetate Mexacarbate 

Butylamine Monoethyl amine 

Captan Monomethyl amine 

Carbaryl Naled 

Carbofuran Napthenic acid 

Carbon disulfide Nitrotoluene 

Chlorpyrifos Parathion 

Coumaphos Phenolsulfonate 

Cresol Phosgene 

Crotonaldehyde Propargite 

Cyclohexane Propylene oxide 

2,4-D (2,4-Dichlorophenoxyacetic acid) Pyrethrins 

Diazinon Quinoline 

Dicamba Resorcinol 

Dichlobenil Strontium 

Dichlone Strychnine 

2,2-Dichloropropionic acid 2,4,5-T (2,4,5-Trichlorophenoxyacetic acid) 

Dichlorvos TDE (Tetrochlorodiphenyl ethane) 

Diethyl amine 2,4,5-TP [2-(2,4,5-Trichlorophenoxy) propanic acid] 

Dimethyl amine Trichlorofon 

Dintrobenzene Triethanolamine dodecylbenzenesulfonate 

Diquat Triethylamine 

Disulfoton Uranium 

Diuron Vanadium 

Epichlorohydrin Vinyl acetate 

Ethion Xylene 

Ethylene diamine Xylenol 

Formaldehyde Zirconium 

Furfural 

Guthion 
HAZARDOUS SUBSTANCES 

Table 2D-4 

EPA Form 3510-2D (8-90)

1. Acetaldehyde 

2. Acetic acid 

3. Acetic anhydride 

4. Acetone cyanohydrin 

5. Acetyl bromide 

6. Acetyl chloride 

7. Acrolein 

8. Acrylonitrile 

9. Adipic acid 

10. Aldrin 

11. Allyl alcohol 

12. Allyl chloride 

13. Aluminum sulfate 

14. Ammonia 

15. Ammonium acetate 

16. Ammonium benzoate 

17. Ammonium bicarbonate 

18. Ammonium bichromate 

19. Ammonium bifluoride 

20. Ammonium bisulfite 

21. Ammonium carbamate 

22. Ammonium carbonate 

23. Ammonium chloride 

24. Ammonium chromate 

25. Ammonium citrate 

26. Ammonium fluoroborate 

27. Ammonium fluoride 

28. Ammonium hydroxide 

29. Ammonium oxalate 

30. Ammonium silicofluoride 

31. Ammonium sulfamate 

32. Ammonium sulfide 

33. Ammonium sulfite 

34. Ammonium tartrate 

35. Ammonium thiocyanate 

36. Ammonium thiosulfate 

37. Amyl acetate 

38. Aniline 

39. Antimony pentachloride 

40. Antimony potassium tartrate 

41. Antimony tribromide 

42. Antimony trichloride 

43. Antimony trifluoride 

44. Antimony trioxide 

45. Arsenic disulfide 

46. Arsenic pentoxide 

47. Arsenic trichloride 

48. Arsenic trioxide 

49. Arsenic trisulfide 

50. Barium cyanide 

51. Benzene 

52. Benzoic acid 

53. Benzonitrile 

54. Benzoyl chloride 

55. Benzyl chloride 

56. Beryllium chloride 

57. Beryllium fluoride 

58. Beryllium nitrate 

59. Butylacetate 

60. n-Butylphthalate 

61. Butylamine 

62. Butyric acid 

63. Cadmium acetate 

64. Cadmium bromide 

65. Cadmium chloride 

66. Calcium arsenate 

67. Calcium arsenite 

69. Calcium carbide 

69. Calcium chromate 

70. Calcium cyanide 

71. Calcium dodecylbenzenesulfonate 

72. Calcium hypochlorite 

73. Captan 

74. Carbaryl 

75. Carbofuran 

76. Carbon disulfide 

77. Carbon tetrachloride 

78. Chlordane 

79. Chlorine 

80. Chlorobenzene 

81. Chloroform 

82. Chloropyrifos 

83. Chlorosulfonic acid 

84. Chromic acetate 

85. Chromic acid 

86. Chromic sulfate 

87. Chromous chloride 

88. Cobaltous bromide 

89. Cobaltous formate 

90. Cobaltous sulfamate 

91. Coumaphos 

92. Cresol 

93. Crotonaldehyde 

94. Cupric acetate 

95. Cupric acetoarsenite 

96. Cupric chloride 

97. Cupric nitrate 

98. Cupric oxalate 

99. Cupric sulfate 

100. Cupric sulfate ammoniated 

101. Cupric tartrate 

102. Cyanogen chloride 

103. Cyclohexane 

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

acid) 

105. 2,4-D esters (2,4- 

Dichlorophenoxyacetic acid esters) 

106. DDT 

107. Diazinon 

108. Dicamba 

109. Dichlobenil 

110. Dichlone 

111. Dichlorobenzene 

112. Dichloropropane 

113. Dichloropropene 

114. Dichloropropene-Dichloproropane mix 

115. 2,2-Dichloropropionic acid 

116. Dichlorvos 

117. Dieldrin 

118. Diethylamine 

119. Dimethylamine 

120. Dinitrobenzene 

121. Dinitrophenol 

122. Dinitrotoluene 

123. Diquat 

124. Disulfoton 

125. Diuron 

126. Dodecylbenzesulfonic acid 

127. Endosulfan 

128. Endrin 

129. Epichlorohydrin 

130. Ethion 

131. Ethylbenzene 

132. Ethylenediamine 

133. Ethylene dibromide 

134. Ethylene dichloride 

135. Ethylene diaminetetracetic acid (EDTA) 

136. Ferric ammonium citrate 

137. Ferric ammonium oxalate 

138. Ferric chloride 

139. Ferric fluoride 

140. Ferric nitrate 

141. Ferric sulfate 

142. Ferrous ammonium sulfate 

143. Ferrous chloride 

144. Ferrous sulfate 

145. Formaldehyde 

146. Formic acid 

147. Fumaric acid 

148. Furfural 

149. Guthion 

150. Heptachlor 

151. Hexachlorocyclopentadiene 

152. Hydrochloric acid 

153. Hydrofluoric acid 

154. Hydrogen cyanide 

155. Hydrogen sulfide 

156. Isoprene 

157. Isopropanolamine 

dodecylbenzenesulfonate 

158. Kelthane 

159. Kepone 

160. Lead acetate 

161. Lead arsenate 

162. Lead chloride 

163. Lead fluoborate 

164. Lead flourite 

165. Lead iodide 

166. Lead nitrate 

167. Lead stearate 

168. Lead sulfate 

169. Lead sulfide 

170. Lead thiocyanate 

171. Lindane 

172. Lithium chromate 

173. Malathion 

174. Maleic acid 

175. Maleic anhydride 

176. Mercaptodimethur 

177. Mercuric cyanide 

178. Mercuric nitrate 

179. Mercuric sulfate 

180. Mercuric thiocyanate 

181. Mercurous nitrate 

182. Methoxychlor 

183. Methyl mercaptan 

184. Methyl methacrylate 

185. Methyl parathion 

186. Mevinphos 

187. Mexacarbate 

188. Monoethylamine 

189. Monomethylamine 

190. Naled 

191. Naphthalene 

192. Naphthenic acid 

193. Nickel ammonium sulfate 

194. Nickel chloride 

195. Nickel hydroxide 
HAZARDOUS SUBSTANCES (Continued)

EPA Form 3510-2D (Rev. 8-90) 

Table 2D-4 

196. Nickel nitrate 

197. Nickel sulfate 

198. Nitric acid 

199. Nitrobenzene 

200. Nitrogen dioxide 

201. Nitrophenol 

202. Nitrotoluene 

203. Paraformaldehyde 

204. Parathion 

205. Pentachlorophenol 

206. Phenol 

207. Phosgene 

208. Phosphoric acid 

209. Phosphorus 

210. Phosphorus oxychloride 

211. Phosphorus pentasulfide 

212. Phosphorus trichloride 

213. Polychlorinated biphenyls (PCB) 

214. Potassium arsenate 

215. Potassium arsenite 

216. Potassium bichromate 

217. Potassium chromate 

218. Potassium cyanide 

219. Potassium hydroxide 

220. Potassium permanganate 

221. Propargite 

222. Propionic acid 

223. Propionic anhydride 

224. Propylene oxide 

225. Pyrethrins 

226. Quinoline 

227. Resorcinol 

228. Selenium oxide 

229. Silver nitrate 

230. Sodium 

231. Sodium arsenate 

232. Sodium arsenite 

233. Sodium bichromate 

234. Sodium bifluoride 

235. Sodium bisulfite 

236. Sodium chromate 

237. Sodium cyanide 

238. Sodium dodecylbenzenesulfonate 

239. Sodium fluoride 

240. Sodium hydrosulfide 

241. Sodium hydroxide 

242. Sodium hypochlorite 

243. Sodium methylate 

244. Sodium nitrite 

245. Sodium phosphate (dibasic) 

246. Sodium phosphate (tribasic) 

247. Sodium selenite 

248. Strontium chromate 

249. Strychnine 

250. Styrene 

251. Sulfuric acid 

252. Sulfur monochloride 

253. 2,4,5-T acid (2,4,5- 

Trichlorophenoxyacetic acid) 

254. 2,4,5-T amines (2,4,5-Trichlorophenoxy 

acetic acid amines) 

255. 2,4,5-T esters (2,4,5 Trichlorophenoxy 

acetic acid esters) 

256. 2,4,5-T salts (2,4,5-Trichlorophenoxy 

acetic acid salts) 

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

propanoic acid) 

258. 2,4,5-TP acid esters (2,4,5- 

Trichlorophenoxy propanoic acid esters) 

259. TDE (Tetrachlorodiphenyl ethane) 

260. Tetraethyl lead 

261. Tetraethyl pyrophosphate 

262. Thallium sulfate 

263. Toluene 

264. Toxaphene 

265. Trichlorofon 

266. Trichloroethylene 

267. Trichlorophenol 

268. Triethanolamine 

dodecylbenzenesulfonate 

269. Triethylamine 

270. Trimethylamine 

271. Uranyl acetate 

272. Uranyl nitrate 

273. Vanadium pentoxide 

274. Vanadyl sulfate 

275. Vinyl acetate 

276. Vinylidene chloride 

277. Xylene 

278. Xylenol 

279. Zinc acetate 

280. Zinc ammonium chloride 

281. Zinc borate 

282. Zinc bromide 

283. Zinc carbonate 

284. Zinc chloride 

285. Zinc cyanide 

286. Zinc fluoride 

287. Zinc formate 

288. Zinc hydrosulfite 

289. Zinc nitrate 

290. Zinc phenolsulfonate 

291. Zinc phosphide 

292. Zinc silicofluoride 

293. Zinc sulfate 

294. Zirconium nitrate 

295. Zirconium potassium flouride 

296. Zirconium sulfate 

297. Zirconium tetrachloride 
LINE DRAWING 

Figure 2D-1 

EPA Form 3510-2D (Rev. 8-90) 

Fiber

Preparation Dyeing Washing Drying 

Grit 

Separator

Neutralization

Tank

Waste

Treatment

Plant #2

Waste

Treatment

Plant #1

20,000

GPD

10,000

GPD

15,000

GPD

45,000 GPD 45,000 GPD

90,000 GPD

Blue River Municipal

Water Supply

30,000 GPD

Blue River

10,000 GPD

Cooling Water

5,000 GPD

To Atmosphere 10,000 GPD

Raw Materials

To Product 

5,000 GPD 10,000

GPD

40,000

GPD

Outfall 002

50,000 GPD

Loss 

6,000 GPD

Solid Waste

4,000 GPD

40,000 GPD 40,000 GPD

36,000 GPD 34,000 GPD

Outfall 001

Stormwate 70,000 GPD + Stormwater r

Max: 20,000 GPD

Schematic of Water Flow 

Brown Mills, Inc. 

City, County, State 
Form Approved. OMB No. 2040-0086. Approval expires 8-31-98.

Please print or type in the unshaded areas only 

EPA I.D. NUMBER (copy from Item 1 of Form 1) 

Form 

2D 

NPDES

New Sources and New Dischargers 

Application for Permit to Discharge Process Wastewater 

I. Outfall Location 

For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water. 

Outfall Number Latitude Longitude 

(list) Deg. Min. Sec. Deg. Min. Sec. 

Receiving Water (name) 

 

II. Discharge Date (When do you expect to begin discharging?) 

III. Flows, Sources of Pollution, and Treatment Technologies 

A. For each outfall, provide a description of: (1) All operations contributing wastewater to the effluent, including process wastewater, sanitary 

wastewater, cooling water, and storm water runoff; (2) The average flow contributed by each operation; and (3) The treatment received by the 

wastewater. Continue on additional sheets if necessary. 

Outfall 

Number 

1. Operations Contributing Flow 

(List) 

2. Average Flow 

(Include Units) 

3. Treatment 

(Description or List codes from Table 2D-1)

 

EPA Form 3510-2D (Rev. 8-90) PAGE 1 of 5 
B. Attach a line drawing showing the water flow through the facility. Indicate sources of intake water, operations contributing wastewater to the 

effluent, and treatment units labeled to correspond to the more detailed descriptions in Item III-A. Construct a water balance on the line drawing 

by showing average flows between intakes, operations, treatment units, and outfalls. If a water balance cannot be determined (e.g., for certain 

mining activities), provide a pictorial description of the nature and amount of any sources of water and any collection or treatment measures. 

C. Except for storm runoff, leaks, or spills, will any of the discharges described in Items III-A be intermittent or seasonal? 

 YES (complete the following table) NO (go to Section IV) 

1. Frequency 2. Flow 

Outfall 

Number a. Days 

Per Week 

(specify average)

b. Months 

Per Year 

(specify average)

a. Maximum Daily 

Flow Rate 

(in mgd) 

b. Maximum 

Total Volume 

(specify with units)

c. Duration 

(in days) 

 

IV. Production 

If there is an applicable production-based effluent guideline or NSPS, for each outfall list the estimated level of production (projection of actual 

production level, not design), expressed in the terms and units used in the applicable effluent guideline or NSPS, for each of the first 3 years of 

operation. If production is likely to vary, you may also submit alternative estimates (attach a separate sheet). 

Year A. Quantity Per Day B. Units Of Measure c. Operation, Product, Material, etc. (specify) 

 

EPA Form 3510-2D (Rev. 8-90) Page 2 of 5 CONTINUE ON NEXT PAGE 
CONTINUED FROM THE FRONT EPA I.D. NUMBER (copy from Item 1 of Form 1) Outfall Number 

V. Effluent Characteristics 

A and B: These items require you to report estimated amounts (both concentration and mass) of the pollutants to be discharged from each of your 

outfalls. Each part of this item addresses a different set of pollutants and should be completed in accordance with the specific instructions for that 

part. Data for each outfall should be on a separate page. Attach additional sheets of paper if necessary. 

General Instructions (See table 2D-2 for Pollutants)

Each part of this item requests you to provide an estimated daily maximum and average for certain pollutants and the source of information. Data 

for all pollutants in Group A, for all outfalls, must be submitted unless waived by the permitting authority. For all outfalls, data for pollutants in Group 

B should be reported only for pollutants which you believe will be present or are limited directly by an effluent limitations guideline or NSPS or 

indirectly through limitations on an indicator pollutant. 

1. Pollutant 

2. Maximum Daily 

Value 

(include units)

3. Average Daily 

Value 

(include units)

4. Source (see instructions)

 

EPA Form 3510-2D (Rev. 8-90) Page 3 of 5 CONTINUE ON REVERSE 
CONTINUED FROM THE FRONT EPA I.D. NUMBER (copy from Item 1 of Form 1) 

C. Use the space below to list any of the pollutants listed in Table 2D-3 of the instructions which you know or have reason to believe will be 

discharged from any outfall. For every pollutant you list, briefly describe the reasons you believe it will be present. 

1. Pollutant 2. Reason for Discharge 

VI. Engineering Report on Wastewater Treatment 

A. If there is any technical evaluation concerning your wastewater treatment, including engineering reports or pilot plant studies, check the 

appropriate box below. 

 Report Available No Report 

B. Provide the name and location of any existing plant(s) which, to the best of your knowledge resembles this production facility with respect to 

production processes, wastewater constituents, or wastewater treatments. 

Name Location 

EPA Form 3510-2D (Rev. 8-90) Page 4 of 5 CONTINUE ON NEXT PAGE 
 EPA I.D. NUMBER (copy from Item 1 of Form 1) 

VII. Other Information (Optional) 

Use the space below to expand upon any of the above questions or to bring to the attention of the reviewer any other information you feel should be 

considered in establishing permit limitations for the proposed facility. Attach additional sheets if necessary. 

VIII. CERTIFICATION 

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system 

designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons 

who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my 

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

possibility of fine and imprisonment for knowing violations. 

A. Name and Official Title (type or print) B. Phone No. 

C. Signature D. Date Signed 

EPA Form 3510-2D (Rev. 8-90) PAGE 5 of 5 
Disclaimer 

This is an updated PDF document that allows you to type your information 

directly into the form, print it, and save the completed form. 

Note: This form can be viewed and saved only using Adobe Acrobat Reader 

version 7.0 or higher, or if you have the full Adobe Professional version. 

Instructions: 

1. Type in your information 

2. Save file (if desired) 

3. Print the completed form 

4. Sign and date the printed copy 

5. Mail it to the directed contact. 
United States 

Environmental Protection 

Agency 

Office of Water 

Enforcement and Permits 

Washington, DC 20460 

EPA Form 3510-2E 

Revised August 1990 

Permits Division 

Application Form 2E — 

Facilities Which Do Not 

Discharge Process 

Wastewater 
EPA Form 3510-2E (8-90) 

Paperwork Reduction Act Notice 

The public reporting burden for this collection of information is 

estimated to average 33 hours per response. This estimate 

includes time for reviewing instructions, searching existing 

data sources, gathering and maintaining the needed data, and 

completing and reviewing the collection of information. Send 

comments regarding the burden estimate or any other aspect 

of this collection of information to the Chief, Information Policy 

Branch (PM-223), US Environmental Protection Agency, 

1200 Pennsylvania Avenue, NW, Washington, DC 20460, and 

to the Office of Information and Regulatory Affairs, Office of 

Management and Budget, Washington, DC 20503, marked 

Attention: Desk Officer for EPA. 
EPA Form 3510-2E (8-90) I-1 

Form 2E Instructions 

Who Must File Form 2E 

EPA Form 3510-2E must be completed in conjunction with 

EPA Form 3510-1 (Form 1). This short form may be used 

only by operators of facilities which discharge only 

nonprocess wastewater (process wastewater is water that 

comes into direct contact with or results from the production 

or use of any raw material, intermediate product, finished 

product, byproduct, waste product, or wastewater) which is 

not regulated by effluent limitations guidelines or new source 

performance standards. The form is intended primarily for 

use by dischargers (new or existing) of sanitary wastes and 

noncontact cooling water. It may not be used for discharges 

of stormwater runoff or by educational, medical, or 

commercial chemical laboratories or by publicly owned 

treatment works (POTW’s). 

Where to File Applications 

The application forms should be sent to the EPA 

Regional Office which covers the State in which the 

facility is located. Form 2E (the short form) must be used 

only when applying for permits in States where the 

NPDES permits program is administered by EPA. For 

facilities located in States which are approved to 

administer the NPDES permits program, the State 

environmental agency should be contacted for proper 

permit application forms and instructions. Information on 

whether a particular program is administered by EPA or 

by a State agency can be obtained from your EPA 

Regional Office. Form 1, Table 1 of the “General 

Instructions” lists the addresses of EPA Regional Offices 

and the States within the jurisdiction of each Office. 

Public Availability of Submitted Information 

You may not claim as confidential any information 

required by this form or Form1, whether the information 

is reported on the forms or in an attachment. Section 

402(j) of the CWA requires that all permit applications 

shall be available to the public. This information will 

therefore be made public upon request. 

You may claim as confidential any information you submit to 

EPA which goes beyond that required by this form or Form 

1. However, confidentiality claims for effluent data must be 

denied. If you do not assert a claim of confidentiality at the 

time of submitting the information, EPA may make the 

information public without further notice. Claims of 

confidentiality will be handled in accordance with EPA’s 

business confidentiality regulations in 40 CFR Part 2. 

Completeness 

Your application will not be considered complete unless 

you answer every question on this form and Form 1 

(except as instructed below). If an item does not apply to 

you, enter “NA” (for “not applicable”) to show that you 

considered the question. 

Followup Requirements for New Dischargers and 

New Sources 

Please note that no later than 2 years after commencement 

of discharge from the proposed facility, you must complete 

and submit Item IV of this form (NPDES Form 2E). At that 

time you must test and report actual rather than estimated 

data for the pollutants or parameters in Item IV, unless 

waived by the permitting authority. 

Definitions 

Significant terms used in these instructions and in the 

form are defined in the Glossary found in the General 

Instructions accompanying Form 1. 

Item I 

Under Part A, list an outfall number. Under Part B, list the 

latitude and longitude to the nearest 15 seconds for this 

outfall. Under Part C, list the name of the outfall’s receiving 

water. When there is more than one outfall, you must submit 

a separate Form 2E (Items I, III, and IV only) for each outfall. 

Item II (New Dischargers Only) 

This item requires your best estimate of the date on 

which your facility will begin to discharge. 

Item III 

In Part A, indicate the general type(s) of wastes to be 

discharged by placing an “x” in the appropriate box(es). 

If “other nonprocess wastewater” is marked, it should be 

identified. If cooling water additives are to be used, they 

must be listed by name under Part B. 

In addition, the composition of the cooling water 

additives should be listed if this information is available. 

The composition of cooling water additives may be found 

on product labels or from manufacturer’s data sheets. 

Item IV — Reporting 

All pollutant levels must be reported as concentration and as 

total mass (except for discharge flow, pH, and temperature). 

Total mass is the total weight of pollutants discharged over a 

day. Use the following abbreviations for units: 

Concentration Mass 

ppm parts per million lbs pounds 

mg/1 milligrams per liter ton tons (English tons) 

ppb parts per billion mg milligrams 

Ug/1 micrograms per liter g grams 

kg kilograms T Tonnes (metric tons) 
EPA Form 3510-2E (8-90) I-2 

A. Existing Sources 

You are required to provide at least one analysis for 

each pollutant or parameter listed by filling in the 

requested information under the applicable column. Data 

reported must be representative of the facility’s current 

operation (average daily value over the previous 365 

days should be reported). Most facilities routinely 

monitor these pollutants or parameters as part of 

existing permit requirements. 

The pollutants or parameters listed are: average flow, 

biochemical oxygen demand (BOD), total suspended 

solids (TSS), fecal coliform (if believed present or if 

sanitary waste is discharged), pH, total residual chlorine 

(if chlorine is used), temperature (winter and summer), 

oil and grease, chemical oxygen demand (COD), total 

organic carbon (TOC) (COD and TOC are only required 

if noncontact cooling water is discharged), and ammonia 

(as N). The analysis of these pollutants or parameters 

must be done in accordance with procedures 

promulgated in 40 CFR Part 136. Grab samples must be 

used for pH, temperature, residual chlorine, oil and 

grease, and fecal coliform. For all other pollutants, 24-

hour composite samples must be used. Any further 

questions on sampling or analysis should be directed to 

your EPA or State permitting authority. The authority 

may request that you do additional testing, if appropriate, 

on a case-by-case basis under Section 308 of the Clean 

Water Act (CWA). 

If you expect a pollutant to be present solely as a result 

of its presence in you intake water, state this information 

on Item VII of the form. 

B. New dischargers 

Your are required to provide an estimated maximum 

daily and average daily value for each pollutant or 

parameter (exceptions noted on the form). Please note 

that followup testing and reporting are required no later 

than 2 years after the facility starts to discharge. 

Sampling and analysis are not required at this time. If, 

however, data from such analyses are available, then 

such data should be reported. The source of the 

estimates is also required. Base your determination of 

whether a pollutant will be present in your discharge on 

your knowledge of the proposed facility’s use of 

maintenance chemicals, and any analyses of your 

effluent or of any similar effluent. You may also provide 

the estimates based on available inhouse or contractor’s 

engineering reports or any other studies performed on 

the proposed facility. If you expect a pollutant or 

parameter to be present solely as a result of its presence 

in your intake water, state this information on Item VII of 

the form. 

In providing the estimates, use the codes in the following 

table to indicate the source of such information. 

 Engineering Study Code 

Actual data from pilot plants .....................................1 

Estimates from other engineering studies ................2 

Data from other similar plants...................................3 

Best professional estimates......................................4 

Others .......................................... specify on the form 

C. Testing Waivers 

To request a waiver from reporting any of these 

pollutants or parameters, the applicant (whether a new 

or existing discharger) must submit to the permitting 

authority a written request specifying which pollutants or 

parameters should be waived and the reasons for 

requesting a waiver. This request should be submitted to 

the permitting authority before or with the permit 

application. The permitting authority may waive the 

requirements for information about any pollutant or 

parameter if he determines that less stringent reporting 

requirements are adequate to support issuance of the 

permit. No extensive documentation of the request will 

normally be needed, but the applicant should contact the 

permitting authority if her or she wishes to receive 

instructions on what his or her particular request should 

contain. 

Item V 

Describe the average frequency of flow and duration of 

any intermittent or seasonal discharge (except for 

stormwater runoff, leaks, or spills). The frequency of flow 

means the number of days or months per year there is 

intermittent discharge. Duration means the number of 

days or hours per discharge. For new dischargers, base 

your answers on your best estimate. 

Item VI 

Describe briefly any treatment system(s) used (or to be 

used for new dischargers), indicating whether the 

treatment system is physical, chemical, biological, 

sludge and disposal, or other. Also give the particular 

type(s) of process(es) used (or to be used). For 

example, if a physical treatment system is used (or will 

be used), specify the processes applied, such as grit 

removal, ammonia stripping, dialysis, etc. 

Item VII 

This item is intended for you to provide any additional 

information (such as sampling results) that you feel 

should be considered by the reviewer in establishing 

permit limitations. Any response here is optional. If you 

wish to demonstrate your eligibility for a “net” effluent 

limitation, i.e., an effluent limitation adjusted to provide 

credit for the pollutant(s) present in your intake water, 

please add a short statement of why you believe you are 

eligible (see §122.45(g)). You will then be contacted by 

the permitting authority for further instructions. 
EPA Form 3510-2E (8-90) I-3 

Item VIII 

The Clean Water Act provides severe penalties for 

submitting false information on this application form. 

Section 309(c)(2) of the Clean Water Act provides that 

“Any person who knowingly makes any false statement, 

representation, or certification in any application, ...shall 

upon conviction, be punished by a fine of no more than 

$10,000 or by imprisonment for not more than six 

months or both.” 

40 CFR Part 122.22 requires the certification to be 

signed as follows: 

a. For a corporation: by a responsible corporate officer. 

A responsible corporate officer means (i) a 

president, secretary, treasurer, or vice-president of 

the corporation in charge of a principal business 

function, or any other person who performs similar 

policy or decision making functions for the 

corporation, or (ii) the manager of one or more 

manufacturing, production, or operating facilities 

employing more than 250 persons or having gross 

annual sales or expenditures exceeding 

$25,000,000 (in second quarter 1980 dollars), if 

authority to sign documents has been assigned or 

delegated to the manager in accordance with 

corporate pocedures. 

b. For a partnership or sole proprietorship: by a general 

partner or the proprietor, respectively; or 

c. For a municipality, State, Federal, or other public 

agency: by either a principal executive officer or 

ranking elected official. For purposes of this section, 

a principal executive officer of a Federal agency 

includes (i) the chief executive officer of the agency, 

or (ii) a senior executive officer having responsibility 

for the overall operations of a principal geographic 

unit of the agency (e.g., Regional Administrators of 

EPA). 
Please print or type in the unshaded areas only. 

EPA ID Number (copy from Item 1 of Form 1) Form Approved. OMB No. 2040-0086. 

Approval expires 5-31-92. 

FORM 

2E 

NPDES 

Facilities Which Do Not Discharge Process Wastewater 

I. RECEIVING WATERS 

For this outfall, list the latitude and longitude, and name of the receiving water(s). 

Outfall Latitude Longitude 

Number (list)

Deg Min Sec Deg Min Sec 

Receiving Water (name)

 

II. DISCHARGE DATE (If a new discharger, the date you expect to begin discharging)

III. TYPE OF WASTE 

A. Check the box(es) indicating the general type(s) of wastes discharged. 

 Sanitary Wastes  Restaurant or Cafeteria Wastes  Noncontact Cooling Water  Other Nonprocess 

Wastewater (Identify)

B. If any cooling water additives are used, list them here. Briefly describe their composition if this information is available. 

IV. EFFLUENT CHARACTERISTICS 

A. Existing Sources — Provide measurements for the parameters listed in the left-hand column below, unless waived by the permitting 

authority (see instructions). 

B. New Dischargers — Provide estimates for the parameters listed in the left-hand column below, unless waived by the permitting 

authority. Instead of the number of measurements taken, provide the source of estimated values (see instructions). 

(3) (or) (4) (1) 

Maximum 

Daily Value 

(include units)

(2) 

Average Daily 

Value (last year) 

(include units)

Pollutant or 

Parameter 

Mass Concentration Mass Concentration 

Number of 

Measurements 

Taken 

(last year)

Source of Estimate 

(if new discharger)

Biochemical Oxygen 

Demand (BOD) 

Total Suspended Solids (TSS) 

Fecal Coliform (if believed present 

or if sanitary waste is discharged) 

Total Residual Chlorine (if 

chlorine is used) 

Oil and Grease 

*Chemical oxygen demand (COD) 

*Total organic carbon (TOC) 

Ammonia (as N) 

Discharge Flow Value 

 

pH (give range) Value 

 

Temperature (Winter) °C °C 

Temperature (Summer) °C °C 

*If noncontact cooling water is discharged 

EPA Form 3510-2E (8-90) Page 1 of 2 
V. Except for leaks or spills, will the discharge described in this form be intermittent or seasonal?

 If yes, briefly describe the frequency of flow and duration.  Yes  No

VI. TREATMENT SYSTEM (Describe briefly any treatment system(s) used or to be used) 

VII. OTHER INFORMATION (Optional)

Use the space below to expand upon any of the above questions or to bring to the attention of the reviewer any other information you feel 

should be considered in establishing permit limitations. Attach additional sheets, if necessary. 

VIII. CERTIFICATION 

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a 

system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or 

persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of 

my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including 

the possibility of fine and imprisonment for knowing violations.

A. Name & Official Title B. Phone No. (area code 

& no.)

C. Signature D. Date Signed 

EPA Form 3510-2E (8-90) Page 2 of 2 
Disclaimer 

This is an updated PDF document that allows you to type your information 

directly into the form, print it, and save the completed form. 

Note: This form can be viewed and saved only using Adobe Acrobat Reader 

version 7.0 or higher, or if you have the full Adobe Professional version. 

Instructions: 

1. Type in your information 

2. Save file (if desired) 

3. Print the completed form 

4. Sign and date the printed copy 

5. Mail it to the directed contact. 
Please print or type in the unshaded areas only. 

EPA ID Number (copy from Item 1 of Form 1) Form Approved. OMB No. 2040-0086 

 Approval expires 5-31-92 

FORM 

2F 

NPDES

U.S. Environmental Protection Agency 

Washington, DC 20460 

Application for Permit to Discharge Storm Water 

Discharges Associated with Industrial Activity

Paperwork Reduction Act Notice 

Public reporting burden for this application is estimated to average 28.6 hours per application, including time for reviewing instructions, searching existing data sources, 

gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate, any other aspect 

of this collection of information, or suggestions for improving this form, including suggestions which may increase or reduce this burden to: Chief, Information Policy 

Branch, PM-223, U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460, or Director, Office of Information and Regulatory 

Affairs, Office of Management and Budget, Washington, DC 20503. 

I. Outfall Location 

For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water. 

A. Outfall Number 

(list) B. Latitude C. Longitude 

D. Receiving Water 

(name) 

 

II. Improvements

A. Are you now required by any Federal, State, or local authority to meet any implementation schedule for the construction, upgrading or operation of wastewater 

treatment equipment or practices or any other environmental programs which may affect the discharges described in this application? This includes, but is not limited 

to, permit conditions, administrative or enforcement orders, enforcement compliance schedule letters, stipulations, court orders, and grant or loan conditions. 

2. Affected Outfalls 4. Final 

1. Identification of Conditions, Compliance Date 

Agreements, Etc. number source of discharge 3. Brief Description of Project a. req. b. proj. 

 

B: You may attach additional sheets describing any additional water pollution (or other environmental projects which may affect your discharges) you now have under 

way or which you plan. Indicate whether each program is now under way or planned, and indicate your actual or planned schedules for construction. 

III. Site Drainage Map

Attach a site map showing topography (or indicating the outline of drainage areas served by the outfalls(s) covered in the application if a topographic map is unavailable) 

depicting the facility including: each of its intake and discharge structures; the drainage area of each storm water outfall; paved areas and buildings within the drainage 

area of each storm water outfall, each known past or present areas used for outdoor storage of disposal of significant materials, each existing structural control measure 

to reduce pollutants in storm water runoff, materials loading and access areas, areas where pesticides, herbicides, soil conditioners and fertilizers are applied; each of 

its hazardous waste treatment, storage or disposal units (including each area not required to have a RCRA permit which is used for accumulating hazardous waste 

under 40 CFR 262.34); each well where fluids from the facility are injected underground; springs, and other surface water bodies which received storm water discharges 

from the facility. 

EPA Form 3510-2F (1-92) Page 1 of 3 Continue on Page 2 
Continued from the Front 

IV. Narrative Description of Pollutant Sources 

A. For each outfall, provide an estimate of the area (include units) of imperious surfaces (including paved areas and building roofs) drained to the outfall, and an estimate of the total surface area 

drained by the outfall. 

Outfall 

Number 

Area of Impervious Surface 

(provide units) 

Total Area Drained 

(provide units) 

Outfall 

Number 

Area of Impervious Surface 

(provide units) 

Total Area Drained 

(provide units) 

 

B. Provide a narrative description of significant materials that are currently or in the past three years have been treated, stored or disposed in a manner to allow exposure 

to storm water; method of treatment, storage, or disposal; past and present materials management practices employed to minimize contact by these materials with 

storm water runoff; materials loading and access areas, and the location, manner, and frequency in which pesticides, herbicides, soil conditioners, and fertilizers are 

applied. 

C. For each outfall, provide the location and a description of existing structural and nonstructural control measures to reduce pollutants in storm water runoff; and a 

description of the treatment the storm water receives, including the schedule and type of maintenance for control and treatment measures and the ultimate disposal 

of any solid or fluid wastes other than by discharge. 

Outfall 

Number Treatment 

List Codes from 

Table 2F-1 

 

V. Nonstormwater Discharges 

A. I certify under penalty of law hat the outfall(s) covered by this application have been tested or evaluated for the presence of nonstormwater discharges, and that all 

nonstormwater discharged from these outfall(s) are identified in either an accompanying Form 2C or From 2E application for the outfall.

Name and Official Title (type or print) Signature Date Signed 

B. Provide a description of the method used, the date of any testing, and the onsite drainage points that were directly observed during a test.

VI. Significant Leaks or Spills 

Provide existing information regarding the history of significant leaks or spills of toxic or hazardous pollutants at the facility in the last three years, including the 

approximate date and location of the spill or leak, and the type and amount of material released. 

EPA Form 3510-2F (1-92) Page 2 of 3 Continue on Page 3
Continued from Page 2

EPA ID Number (copy from Item 1 of Form 1)

 

VII. Discharge Information

A, B, C, & D: See instructions before proceeding. Complete one set of tables for each outfall. Annotate the outfall number in the space provided. 

 Table VII-A, VII-B, VII-C are included on separate sheets numbers VII-1 and VII-2. 

E. Potential discharges not covered by analysis – is any toxic pollutant listed in table 2F-2, 2F-3, or 2F-4, a substance or a component of a substance which you 

currently use or manufacture as an intermediate or final product or byproduct? 

 Yes (list all such pollutants below) No (go to Section IX)

VIII. Biological Toxicity Testing Data 

Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on any of your discharges or on a receiving water in 

relation to your discharge within the last 3 years? 

 Yes (list all such pollutants below) No (go to Section IX) 

IX. Contract Analysis Information 

Were any of the analyses reported in Item VII performed by a contract laboratory or consulting firm? 

 Yes (list the name, address, and telephone number of, and pollutants 

 analyzed by, each such laboratory or firm below) 

 No (go to Section X) 

A. Name B. Address C. Area Code & Phone No. D. Pollutants Analyzed 

 

X. Certification 

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure 

that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system or those persons 

directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that 

there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. 

A. Name & Official Title (Type Or Print) B. Area Code and Phone No. 

C. Signature D. Date Signed 

EPA Form 3510-2F (1-92) Page 3 of 3 
 EPA ID Number (copy from Item 1 of Form 1) Form Approved. OMB No. 2040-0086 

 Approval expires 5-31-92 

VII. Discharge information (Continued from page 3 of Form 2F) 

Part A – You must provide the results of at least one analysis for every pollutant in this table. Complete one table for each outfall. See instructions for additional details. 

Maximum Values 

(include units) 

Average Values 

(include units) 

Pollutant 

and 

CAS Number 

(if available) 

Grab Sample 

Taken During 

First 20 

Minutes 

Flow-Weighted 

Composite 

Grab Sample 

Taken During 

First 20 

Minutes 

Flow-Weighted 

Composite 

Number 

of 

Storm 

Events 

Sampled Sources of Pollutants 

Oil and Grease N/A 

Biological Oxygen 

Demand (BOD5) 

Chemical Oxygen 

Demand (COD) 

Total Suspended 

Solids (TSS) 

Total Nitrogen 

Total Phosphorus 

pH Minimum Maximum Minimum Maximum 

Part B – List each pollutant that is limited in an effluent guideline which the facility is subject to or any pollutant listed in the facility’s NPDES permit for its process 

wastewater (if the facility is operating under an existing NPDES permit). Complete one table for each outfall. See the instructions for additional details and 

requirements. 

Maximum Values 

(include units) 

Average Values 

(include units) 

Pollutant 

and 

CAS Number 

(if available)

Grab Sample 

Taken During 

First 20 

Minutes 

Flow-Weighted 

Composite 

Grab Sample 

Taken During 

First 20 

Minutes 

Flow-Weighted 

Composite 

Number 

of 

Storm 

Events 

Sampled Sources of Pollutants 

 

EPA Form 3510-2F (1-92) Page VII-1 Continue on Reverse
Continued from the Front 

Part C - List each pollutant shown in Table 2F-2, 2F-3, and 2F-4 that you know or have reason to believe is present. See the instructions for additional details and 

requirements. Complete one table for each outfall. 

Maximum Values 

(include units) 

Average Values 

(include units) 

Pollutant 

and 

CAS Number 

(if available)

Grab Sample 

Taken During 

First 20 

Minutes 

Flow-Weighted 

Composite 

Grab Sample 

Taken During 

First 20 

Minutes 

Flow-Weighted 

Composite 

Number 

of 

Storm 

Events 

Sampled Sources of Pollutants 

 

 

 

 

 

Part D – Provide data for the storm event(s) which resulted in the maximum values for the flow weighted composite sample. 

1. 

Date of 

Storm 

Event

2. 

Duration 

of Storm Event 

(in minutes)

3. 

Total rainfall 

during storm event 

(in inches)

4. 

Number of hours between 

beginning of storm measured 

and end of previous 

measurable rain event

5. 

Maximum flow rate during 

rain event 

(gallons/minute or 

specify units)

6. 

Total flow from 

rain event 

(gallons or specify units)

 

7. Provide a description of the method of flow measurement or estimate. 

EPA Form 3510-2F (1-92) Page VII-2 
EPA Form 3510-2F (Rev. 1-92) I - 1 

Instructions – Form 2F 

Application for Permit to Discharge Storm Water 

Associated with Industrial Activity 

Who Must File Form 2F 

Form 2F must be completed by operators of facilities which discharge storm water associated with industrial 

activity or by operators of storm water discharges that EPA is evaluating for designation as a significant 

contributor of pollutants to waters of the United States, or as contributing to a violation of a water quality 

standard. 

Operators of discharges which are composed entirely of storm water must complete Form 2F (EPA Form 

3510-2F) in conjunction with Form 1 (EPA Form 3510-1). 

Operators of discharges of storm water which are combined with process wastewater (process wastewater is 

water that comes into direct contact with or results from the production or use of any raw material, 

intermediate product, finished product, byproduct, waste product, or wastewater) must complete and submit 

Form 2F, Form 1, and Form 2C (EPA Form 3510-2C). 

Operators of discharges of storm water which are combined with nonprocess wastewater (nonprocess 

wastewater includes noncontact cooling water and sanitary wastes which are not regulated by effluent 

guidelines or a new source performance standard, except discharges by educational, medical, or commercial 

chemical laboratories) must complete Form 1, Form 2F, and Form 2E (EPA Form 3510 2E). 

Operators of new sources or new discharges of storm water associated with industrial activity which will be 

combined with other nonstormwater new sources or new discharges must submit Form 1, Form 2F, and Form 

2D (EPA Form 3510-2D). 

Where to File Applications 

The application forms should be sent to the EPA Regional Office which covers the State in which the facility is 

located. Form 2F must be used only when applying for permits in States where the NPDES permits program 

is administered by EPA. For facilities located in States which are approved to administer the NPDES permits 

program, the State environmental agency should be contacted for proper permit application forms and 

instructions. 

Information on whether a particular program is administered by EPA or by a State agency can be obtained 

from your EPA Regional Office. Form 1, Table 1 of the “General Instructions” lists the addresses of EPA 

Regional Offices and the States within the jurisdiction of each Office. 

Completeness 

Your application will not be considered complete unless you answer every question on this form and on Form 

1. If an item does not apply to you, enter “NA” (for not applicable) to show that you considered the question. 

Public Availability of Submitted Information 

You may not claim as confidential any information required by this form or Form 1, whether the information is 

reported on the forms or in an attachment. Section 402(j) of the Clean Water Act requires that all permit 

applications will be available to the public. This information will be made available to the public upon request. 

Any information you submit to EPA which goes beyond that required by this form, Form 1, or Form 2C you 

may claim as confidential, but claims for information which are effluent data will be denied. 

If you do not assert a claim of confidentiality at the time of submitting the information, EPA may make the 

information public without further notice to you. Claims of confidentiality will be handled in accordance with 

EPA's business confidentiality regulations at 40 CFR Part 2. 

Definitions 

All significant terms used in these instructions and in the form are defined in the glossary found in the General 

Instructions which accompany Form 1. 

EPA ID Number 

Fill in your EPA Identification Number at the top of each odd numbered page of Form 2F. You may copy this 

number directly from item I of Form 1. 
EPA Form 3510-2F (Rev. 1-92) I - 2 

Item I 

You may use the map you provided for item XI of Form 1 to determine the latitude and longitude of each of 

your outfalls and the name of the receiving water. 

Item 11-A 

If you check “yes” to this question, complete all parts of the chart, or attach a copy of any previous submission 

you have made to EPA containing the same information. 

Item 11-B 

You are not required to submit a description of future pollution control projects if you do not wish to or if none 

is planned. 

Item III 

Attach a site map showing topography (or indicating the outline of drainage areas served by the outfall(s) 

covered in the application if a topographic map is unavailable) depicting the facility including: 

each of its drainage and discharge structures; 

the drainage area of each storm water outfall; 

paved areas and building within the drainage area of each storm water outfall, each known past or 

present areas used for outdoor storage or disposal of significant materials, each existing structural 

control measure to reduce pollutants in storm water runoff, materials loading and access areas, areas 

where pesticides, herbicides, soil conditioners and fertilizers are applied; 

each of its hazardous waste treatment, storage or disposal facilities (including each area not required 

to have a RCRA permit which is used for accumulating hazardous waste for less than 90 days under 

40 CFR 262.34); 

each well where fluids from the facility are injected underground; and 

springs, and other surface water bodies which receive storm water discharges from the facility; 

Item IV-A 

For each outfall, provide an estimate of the area drained by the outfall which is covered by impervious 

surfaces. For the purpose of this application, impervious surfaces are surfaces where storm water runs off at 

rates that are significantly higher than background rates (e.g., predevelopment levels) and include paved 

areas, building roofs, parking lots, and roadways. Include an estimate of the total area (including all 

impervious and pervious areas) drained by each outfall. The site map required under item III can be used to 

estimate the total area drained by each outfall. 

Item IV-B 

Provide a narrative description of significant materials that are currently or in the past three years have been 

treated, stored, or disposed in a manner to allow exposure to storm water; method of treatment, storage or 

disposal of these materials; past and present materials management practices employed, in the last three 

years, to minimize contact by these materials with storm water runoff; materials loading and access areas; 

and the location, manner, and frequency in which pesticides, herbicides, soil conditioners, and fertilizers are 

applied. Significant materials should be identified by chemical name, form (e.g., powder, liquid, etc.), and type 

of container or treatment unit. Indicate any materials treated, stored, or disposed of together. “Significant 

materials” includes, but is not limited to: raw materials; fuels; materials such as solvents, detergents, and 

plastic pellets; finished materials such as metallic products; raw materials used in food processing or 

production; hazardous substances designated under Section 101 (14) of CERCLA; any chemical the facility is 

required to report pursuant to Section 313 of Title III of SARA; fertilizers; pesticides; and waste products such 

as ashes, slag and sludge that have the potential to be released with storm water discharges. 

Item IV-C 

For each outfall, structural controls Include structures which enclose material handling or storage areas, 

covering materials, berms, dikes, or diversion ditches around manufacturing, production, storage or treatment 

units, retention ponds, etc. Nonstructural controls include practices such as spill prevention plans, employee 

training, visual inspections, preventive maintenance, and housekeeping measures that are used to prevent or 

minimize the potential for releases of pollutants. 
EPA Form 3510-2F (Rev. 1-92) I - 3 

Item V 

Provide a certification that all outfalls that should contain storm water discharges associated with industrial 

activity have been tested or evaluated for the presence of non-storm water discharges which are not covered 

by an NPDES permit. Tests for such non-storm water discharges may include smoke tests, fluorometric dye 

tests, analysis of accurate schematics, as well as other appropriate tests. Part B must include a description of 

the method used, the date of any testing, and the onsite drainage points that were directly observed during a 

test. All non-storm water discharges must be identified in a Form 2C or Form 2E which must accompany this 

application (see beginning of instructions under section titled “Who Must File Form 2F” for a description of 

when Form 2C and Form 2E must be submitted). 

Item VI 

Provide a description of existing information regarding the history of significant leaks or spills of toxic or 

hazardous pollutants at the facility in the last three years. 

Item VII-A, B, and C 

These items require you to collect and report data on the pollutants discharged for each of your outfalls. Each 

part of this item addresses a different set of pollutants and must be completed in accordance with the specific 

instructions for that part. The following general instructions apply to the entire item. 

General Instructions 

Part A requires you to report at least one analysis for each pollutant listed. Parts B and C require you to report 

analytical data in two ways. For some pollutants addressed in Parts B and C, if you know or have reason to 

know that the pollutant is present in your discharge, you may be required to list the pollutant and test (sample 

and analyze) and report the levels of the pollutants in your discharge. For all other pollutants addressed in 

Parts B and C, you must list the pollutant if you know or have reason to know that the pollutant is present in 

the discharge, and either report quantitative data for the pollutant or briefly describe the reasons the pollutant 

is expected to be discharged. (See specific instructions on the form and below for Parts A through C.) Base 

your determination that a pollutant is present in or absent from your discharge on your knowledge of your raw 

materials, material management practices, maintenance chemicals, history of spills and releases, 

intermediate and final products and byproducts, and any previous analyses known to you of your effluent or 

similar effluent. 

A. Sampling: The collection of the samples for the reported analyses should be supervised by a person 

experienced in performing sampling of industrial wastewater or storm water discharges. You may contact 

EPA or your State permitting authority for detailed guidance on sampling techniques and for answers to 

specific questions. Any specific requirements contained in the applicable analytical methods should be 

followed for sample containers, sample preservation, holding times, the collection of duplicate samples, 

etc. The time when you sample should be representative, to the extent feasible, of your treatment system 

operating properly with no system upsets. Samples should be collected from the center of the flow 

channel, where turbulence is at a maximum, at a site specified in your present permit, or at any site 

adequate for the collection of a representative sample. 

For pH, temperature, cyanide, total phenols, residual chlorine, oil and grease, and fecal coliform, grab 

samples taken during the first 30 minutes (or as soon thereafter as practicable) of the discharge must be 

used (you are not required to analyze a flow-weighted composite for these parameters). For all other 

pollutants both a grab sample collected during the first 30 minutes (or as soon thereafter as practicable) 

of the discharge and a flow-weighted composite sample must be analyzed. However, a minimum of one 

grab sample may be taken for effluents from holding ponds or other impoundments with a retention period 

of greater than 24 hours. 

All samples shall be collected from the discharge resulting from a storm event that is greater than 0.1 

inches and at least 72 hours from the previously measurable (greater than 0.1 inch rainfall) storm event. 

Where feasible, the variance in the duration of the event and the total rainfall of the event should not 

exceed 50 percent from the average or median rainfall event in that area. 

A grab sample shall be taken during the first thirty minutes of the discharge (or as soon thereafter as 

practicable), and a flow-weighted composite shall be taken for the entire event or for the first three hours 

of the event. 
EPA Form 3510-2F (Rev. 1-92) I - 4 

Grab and composite samples are defined as follows: 

Grab sample: An individual sample of at least 100 milliliters collected during the first thirty minutes 

(or as soon thereafter as practicable) of the discharge. This sample is to be analyzed separately from 

the composite sample. 

Flow-weighted Composite sample: A flow-weighted composite sample may be taken with a 

continuous sampler that proportions the amount of sample collected with the flow rate or as a 

combination of a minimum of three sample aliquots taken in each hour of discharge for the entire 

event or for the first three hours of the event, with each aliquot being at least 100 milliliters and 

collected with a minimum period of fifteen minutes between aliquot collections. The composite must 

be flow proportional; either the time interval between each aliquot or the volume of each aliquot must 

be proportional to either the stream flow at the time of sampling or the total stream flow since the 

collection of the previous aliquot. Aliquots may be collected manually or automatically. Where GC/MS 

Volatile Organic Analysis (VOA) is required, aliquots must be combined in the laboratory immediately 

before analysis. Only one analysis for the composite sample is required. 

Data from samples taken in the past may be used, provided that: 

All data requirements are met; 

Sampling was done no more than three years before submission; and 

All data are representative of the present discharge. 

Among the factors which would cause the data to be unrepresentative are significant changes in 

production level, changes in raw materials, processes, or final products, and changes in storm water 

treatment. When the Agency promulgates new analytical methods in 40 CFR Part 136, EPA will provide 

information as to when you should use the new methods to generate data on your discharges. Of course, 

the Director may request additional information, including current quantitative data, if they determine it to 

be necessary to assess your discharges. The Director may allow or establish appropriate site-specific 

sampling procedures or requirements including sampling locations, the season in which the sampling 

takes place, the minimum duration between the previous measurable storm event and the storm event 

sampled, the minimum or maximum level of precipitation required for an appropriate storm event, the form 

of precipitation sampled (snow melt or rainfall), protocols for collecting samples under 40 CFR Part 136, 

and additional time for submitting data on a case-by-case basis. 

B. Reporting: All levels must be reported as concentration and mass (note: grab samples are reported in 

terms of concentration). You may report some or all of the required data by attaching separate sheets of 

paper instead of filling out pages VII-1 and VII-2 if the separate sheets contain all the required information 

in a format which is constant with pages VII-1 and VII-2 in spacing and identification of pollutants and 

columns. Use the following abbreviations in the columns headed “Units.” 

Concentration Mass

ppm parts per million lbs pounds 

mg/1 milligrams per liter ton tons (English tons) 

ppb parts per billion mg milligrams 

ug/1 micrograms per liter g grams 

kg kilograms T tonnes (metric tons) 

All reporting of values for metals must be in terms of “total recoverable metal,” unless: 

(1) An applicable, promulgated effluent limitation or standard specifies the limitation for the metal in 

dissolved, valent, or total form; or 

(2) All approved analytical methods for the metal inherently measure only its dissolved form (e.g., 

hexavalent chromium); or 

(3) The permitting authority has determined that in establishing case-by-case limitations it is 

necessary to express the limitations on the metal in dissolved, valent, or total form to carry out the 

provisions of the CWA. If you measure only one grab sample and one flow-weighted composite 
EPA Form 3510-2F (Rev. 1-92) I - 5 

sample for a given outfall, complete only the “Maximum Values” columns and insert “1” into the 

“Number of Storm Events Sampled” column. The permitting authority may require you to conduct 

additional analyses to further characterize your discharges. 

If you measure more than one value for a grab sample or a flow-weighted composite sample for a given 

outfall and those values are representative of your discharge, you must report them. You must describe 

your method of testing and data analysis. You also must determine the average of all values within the 

last year and report the concentration and mass under the “Average Values” columns, and the total 

number of storm events sampled under the “Number of Storm Events Sampled” columns. 

C. Analysis: You must use test methods promulgated in 40 CFR Part 136; however, if none has been 

promulgated for a particular pollutant, you may use any suitable method for measuring the level of the 

pollutant in your discharge provided that you submit a description of the method or a reference to a 

published method. Your description should include the sample holding time, preservation techniques, and 

the quality control measures which you used. If you have two or more substantially identical outfalls, you 

may request permission from your permitting authority to sample and analyze only one outfall and submit 

the results of the analysis for other substantially identical outfalls. If your request is granted by the 

permitting authority, on a separate sheet attached to the application form, identify which outfall you did 

test, and describe why the outfalls which you did not test are substantially identical to the outfall which 

you did test. 

Part VII-A 

Part VII-A must be completed by all applicants for all outfalls who must complete Form 2F. 

Analyze a grab sample collected during the first thirty minutes (or as soon thereafter as practicable) of the 

discharge and flow-weighted composite samples for all pollutants in this Part, and report the results except 

use only grab samples for pH and oil and grease. See discussion in General Instructions to Item VII for 

definitions of grab sample collected during the first thirty minutes of discharge and flow-weighted composite 

sample. The “Average Values” column is not compulsory but should be filled out if data are available. 

Part VII B 

List all pollutants that are limited in an effluent guideline which the facility is subject to (see 40 CFR 

Subchapter N to determine which pollutants are limited in effluent guidelines) or any pollutant listed in the 

facility's NPDES permit for its process wastewater (if the facility is operating under an existing NPIDES 

permit). Complete one table for each outfall. See discussion in General instructions to item VII for definitions 

of grab sample collected during the first thirty minutes (or as soon thereafter as practicable) of discharge and 

flow-weighted composite sample. The “Average Values” column is not compulsory but should be filled out if 

data are available. 

Analyze a grab sample collected during the first thirty minutes of the discharge and flow-weighted composite 

samples for all pollutants in this Part, and report the results, except as provided in the General Instructions. 

Part VII-C 

Part V11-C must be completed by all applicants for all outfalls which discharge storm water associated with 

industrial activity, or that EPA is evaluating for designation as a significant contributor of pollutants to waters 

of the United States, or as contributing to a violation of a water quality standard. Use both a grab sample and 

a composite sample for all pollutants you analyze for in this part except use grab samples for residual chlorine 

and fecal coliform. The “Average Values” column is not compulsory but should be filled out if data are 

available. Part C requires you to address the pollutants in Table 2F-2, 2F-3, and 2F-4 for each outfall. 

Pollutants in each of these Tables are addressed differently. 

Table 2F-2: For each outfall, list all pollutants in Table 2F-2 that you know or have reason to believe are 

discharged (except pollutants previously listed in Part VII-B). If a pollutant is limited in an effluent guideline 

limitation which the facility is subject to, the pollutant must be analyzed and reported in Part VII-B. If a 

pollutant in Table 2F-2 is indirectly limited by an effluent guideline limitation through an indicator (e.g., use of 

TSS as an indicator to control the discharge of iron and aluminum), you must analyze for it and report the 

data in Part VII-B. For other pollutants listed in Table 2F-2 (those not limited directly or indirectly by an effluent 

limitation guideline), that you know or have reason to believe are discharged, you must either report 

quantitative data or briefly describe the reasons the pollutant is expected to be discharged. 
EPA Form 3510-2F (Rev. 1-92) I - 6 

Table 2F-3: For each outfall, list all pollutants in Table 2F-3 that you know or have reason to believe are 

discharged. For every pollutant in Table 2F-3 expected to be discharged in concentrations of 10 ppb or 

greater, you must submit quantitative data. For acrolein, acrylonitrile, 2,4 dinitrophenol, and 2-methyl-4,6 

dinitrophenol, you must submit quantitative data if any of these four pollutants is expected to be discharged in 

concentrations of 100 ppb or greater. For every pollutant expected to be discharged in concentrations less 

than 10 ppb (or 100 ppb for the four pollutants listed above), then you must either submit quantitative data or 

briefly describe the reasons the pollutant is expected to be discharged. 

Small Business Exemption - If you are a “small business,” you are exempt from the reporting requirements 

for the organic toxic pollutants listed in Table 2F-3. There are two ways in which you can qualify as a small 

business”. If your facility is a coal mine, and if your probable total annual production is less than 100,000 tons 

per year, you may submit past production data or estimated future production (such as a schedule of 

estimated total production under 30 CFR 795.14(c)) instead of conducting analyses for the organic toxic 

pollutants. If your facility is not a coal mine, and if your gross total annual sales for the most recent three 

years average less than $100,000 per year (in second quarter 1980 dollars), you may submit sales data for 

those years instead of conducting analyses for the organic toxic pollutants. The production or sales data must 

be for the facility which is the source of the discharge. The data should not be limited to production or sales 

for the process or processes which contribute to the discharge, unless those are the only processes at your 

facility. For sales data, in situations involving intracorporate transfer of goods and services, the transfer price 

per unit should approximate market prices for those goods and services as closely as possible. Sales figures 

for years after 1980 should be indexed to the second quarter of 1980 by using the gross national product 

price deflator (second quarter of 1980=100). This index is available in National Income and Product Accounts 

of the United States (Department of Commerce, Bureau of Economic Analysis). 

Table 2F-4: For each outfall, list any pollutant in Table 2F-4 that you know or believe to be present in the 

discharge and explain why you believe it to be present. No analysis is required, but if you have analytical 

data, you must report them. Note: Under 40 CFR 117.12(a)(2), certain discharges of hazardous substances 

(listed at 40 CFR 177.21 or 40 CFR 302.4) may be exempted from the requirements of section 311 of CWA, 

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

hazardous substances. A discharge of a particular substance may be exempted if the origin, source, and 

amount of the discharged substances are identified in the NPDES permit application or in the permit, if the 

permit contains a requirement for treatment of the discharge, and if the treatment is in place. To apply for an 

exclusion of the discharge of any hazardous substance from the requirements of section 311, attach 

additional sheets of paper to your form, setting forth the following information: 

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

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

3. The treatment which is to be provided for the discharge by; 

a. An onsite treatment system separate from any treatment system treating your normal discharge; 

b. A treatment system designed to treat your normal discharge and which is additionally capable of 

treating the amount of the substance identified under paragraph 1 above; or 

c. Any combination of the above. 

See 40 CFR 117.12(a)(2) and (c), published on August 29, 1979, in 44 FR 50766, or contact your Regional 

Office (Table I on Form 1, Instructions), for further information on exclusions from section 311. 

Part VII-D 

If sampling is conducted during more than one storm event, you only need to report the information requested 

in Part VII-D for the storm event(s) which resulted in any maximum pollutant concentration reported in Part 

VII-A, VII-B, or VII-C. 

Provide flow measurements or estimates of the flow rate, and the total amount of discharge for the storm 

event(s) sampled, the method of flow measurement, or estimation. Provide the data and duration of the storm 

event(s) sampled, rainfall measurements, or estimates of the storm event which generated the sampled runoff 

and the duration between the storm event sampled and the end of the previous measurable (greater than 0.1 

inch rainfall) storm event. 
EPA Form 3510-2F (Rev. 1-92) I - 7 

Part VII-E 

List any toxic pollutant listed in Tables 2F-2, 2F-3, or 2F-4 which you currently use or manufacture as an 

intermediate or final product or byproduct. In addition, if you know or have reason to believe that 2,3,7,8-

tetrachlorodibenzo-p-dioxin (TCDD) is discharged or if you use or manufacture 2,4,5-trichlorophenoxy acetic 

acid (2,4,5,-T); 2-(2,4,5-trichlorophenoxy) propanoic acid (Silvex, 2,4,5,-TP); 2-(2,4,5-trichlorophenoxy) ethyl, 

2,2-dichloropropionate (Erbon); 0,0-dimethyl 0-(2,4,5-trichlorphenyl) phosphorothioate (Ronnel); 2,4,5-

trichlorophenol (TCP); or hexachlorophene (HCP); then list TCDD. The Director may waive or modify the 

requirement if you demonstrate that it would be unduly burdensome to identify each toxic pollutant and the 

Director has adequate information to issue your permit. You may not claim this information as confidential; 

however, you do not have to distinguish between use or production of the pollutants or list the amounts. 

Item VIIl 

Self explanatory. The permitting authority may ask you to provide additional details after your application is 

received. 

Item X 

The Clean Water Act provides for severe penalties for submitting false information on this application form. 

Section 309(c)(4) of the Clean Water Act provides that “Any person who knowingly makes any false material 

statement, representation, or certification in any application, . . . shall upon conviction, be punished by a fine 

of not more than $10,000 or by imprisonment for not more than 2 years, or by both. If a conviction of such 

person is for a violation committed after a first conviction of such person under this paragraph, punishment 

shall be by a fine of not more than $20,000 per day of violation, or by imprisonment of not more than 4 years, 

or by both.” 40 CFR Part 122.22 requires the certification to be signed as follows: 

(A) For a corporation: by a responsible corporate official. For purposes of this section, a responsible 

corporate official means (i) a president, secretary, treasurer, or vice president of the corporation in charge 

of a principal business function, or any other person who performs similar policy- or decision-making 

functions for the corporation or (ii) the manager of one or more manufacturing, production, or operating 

facilities employing more than 250 persons or having gross annual sales or expenditures exceeding 

$25,000,000 (in second quarter 1980 dollars), if authority to sign documents has been assigned or 

delegated to the manager in accordance with corporate procedures. 

Note: EPA does not require specific assignments or delegation of authority to responsible corporate 

officers identified in 122.22(a)(1)(i) The Agency will presume that these responsible corporate officers 

have the requisite authority to sign permit applications unless the corporation has notified the Director to 

the contrary. Corporate procedures governing authority to sign permit applications may provide for 

assignment or delegation to applicable corporate position under 122.22(a)(1)(ii) rather than to specific 

individuals. 

(B) For a partnership or sole proprietorship: by a general partner or the proprietor, respectively; or 

(C) For a municipality, State, Federal, or other public agency: by either a principal executive officer or 

ranking elected official. For purposes of this section, a principal executive officer of a Federal agency 

includes (i) the chief executive officer of the agency, or (ii) a senior executive officer having responsibility 

for the overall operations of a principal geographic unit of the agency (e.g., Regional Administrators of 

EPA). 
EPA Form 3510-2F (Rev. 1-92) I - 8 

Table 2F-1 

Codes for Treatment Units 

Physical Treatment Processes 

1-A Ammonia Stripping 1-M Grit Removal 

1-B Dialysis 1-N Microstraining 

1-C Diatomaceous Earth Filtration 1-0 Mixing 

1-D Distillation 1-P Moving Bed Filters 

1-E Electrodialysis 1-Q Multimedia Filtration 

1-F Evaporation 1-R Rapid Sand Filtration 

1-G Flocculation 1-S Reverse Osmosis (Hyperfiltration) 

1-H Flotation 1-T Screening 

1-1 Foam Fractionation 1-U Sedimentation (Setting) 

1-J Freezing 1-V Slow Sand Filtration 

1-K Gas-Phase Separation 1-W Solvent Extraction 

1-L Grinding (Comminutors) 1-X Sorption 

Chemical Treatment Processes 

2-A Carbon Adsorption 2-G Disinfection (Ozone) 

2-B Chemical Oxidation 2-H Disinfection (Other) 

2-C Chemical Precipitation 2-I Electrochemical Treatment 

2-D Coagulation 2-J Ion Exchange 

2-E Dechlorination 2-K Neutralization 

2-F Disinfection (Chlorine) 2-L Reduction 

Biological Treatment Processes 

3-A Activated Sludge 3-E Pre-Aeration 

3-B Aerated Lagoons 3-F Spray Irrigation/Land Application 

3-C Anaerobic Treatment 3-G Stabilization Ponds 

3-D Nitrification-Denitrification 3-H Trickling Filtration 

Other Processes 

4-A Discharge to Surface Water 4-C Reuse/Recycle of Treated Effluent 

4-B Ocean Discharge Through Outfall 4-D Underground Injection 

Sludge Treatment and Disposal Processes

5-A Aerobic Digestion 5-M Heat Drying 

5-B Anaerobic Digestion 5-N Heat Treatment 

5-C Belt Filtration 5-0 Incineration 

5-D Centrifugation 5-P Land Application 

5-E Chemical Conditioning 5-0 Landfill 

5-F Chlorine Treatment 5-R Pressure Filtration 

5-G Composting 5-S Pyrolysis 

5-H Drying Beds 5-T Sludge Lagoons 

5-I Elutriation 5-U Vacuum Filtration 

5-J Flotation Thickening 5-V Vibration 

5-K Freezing 5-W Wet Oxidation 

5-L Gravity Thickening 
EPA Form 3510-2F (Rev. 1-92) I - 9 

Table 2F-2

Conventional and Nonconventional Pollutants 

Bromide 

Chlorine, Total Residual 

Color 

Fecal Coliform 

Fluoride 

Nitrate-Nitrite 

Nitrogen, Total Organic 

Oil and Grease 

Phosphorus, Total 

Radioactivity 

Sulfate 

Sulfite 

Surfactants 

Aluminum, Total 

Barium, Total 

Boron, Total 

Cobalt Total 

Iron, Total 

Magnesium, Total 

Molybdenum, Total 

Manganese, Total 

Tin, Total 

Titanium, Total 
EPA Form 3510-2F (Rev. 1-92) I - 10 

Table 2F-3 

Toxic Pollutants

Toxic Pollutants and Total Phenol 

Antimony, Total Copper, Total Silver, Total 

Arsenic, Total Lead, Total Thallium, Total 

Beryllium, Total Mercury, Total Zinc, Total 

Cadmium, Total Nickel, Total Cyanide, Total 

Chromium, Total Selenium, Total Phenols, Total 

GC/MS Fraction Volatiles Compounds 

Acrolein Dichlorobromomethane 1,1,2,2,-Tetrachloroethane 

Acrylonitrile 1,1-Dichloroethane Tetrachloroethylene 

Benzene 1,2-Dichloroethane Toluene 

Bromoform 1,1-Dichloroethylene 1,2-Trans-Dichloroethylene 

Carbon Tetrachloride 1,2-Dichloropropane 1,1,1-Trichloroethane 

Chlorobenzene 1.3-Dichloropropylene 1,1,2-Trichloroethane 

Chlorodibromomethane Ethylbenzene Trichloroethylene 

Chloroethane Methyl Bromide Vinyl Chloride 

2-Chloroethylvinyl Ether Methyl Chloride 

Chloroform Methylene Chloride 

Acid Compounds

2-Chlorophenol 2,4-Dinitrophenol Pentachlorophenol 

2,4-Dichlorophenol 2-Nitrophenol Phenol 

2,4-Dimethylphenol 4-Nitrophenol 2,4,6-Trichlorophenol 

4,6-Dinitro-O-Cresol p-Chloro-M-Cresol 2-methyl-4,6 dinitrophenol 

Base/Neutral

Acenaphthene 2-Chloronaphthalene Fluroranthene 

Acenaphthylene 4-Chlorophenyl Phenyl Ether Fluorene 

Anthracene Chrysene Hexachlorobenzene 

Benzidine Dibenzo(a,h)anthracene Hexachlorobutadiene 

Benzo(a)anthracene 1,2-Dichlorobenzene Hexachloroethane 

Benzo(a)pyrene 1,3-Dichlorobenzene lndeno(1,2,3-cd)pyrene 

3,4-Benzofluoranthene 1,4-Dichlorobenzene Isophorone 

Benzo(ghi)perylene 3,3'-Dichlorobenzidine Napthalene 

Benzo(k)fluoranthene Diethyl Phthalate Nitrobenzene 

Bis(2-chloroethoxy)methane Dimethyl Phthalate N-Nitrosodimethylamine 

Bis(2-chloroethyl)ether Di-N-Butyl Phthalate N-Nitrosodi-N-Propylamine 

Bis(2-chloroisopropyl)ether 2,4-Dinitrotoluene N-Nitrosodiphenylamine 

Bis(2-ethylyhexyl)phthalate 2,6-Dinitrotoluene Phenanthrene 

4-Bromophenyl Phenyl Ether Di-N-Octyphthalate Pyrene 

Butylbenzyl Phthalate 1,2-Diphenylhydrazine (as Azobenzene) 1,2,4-Trichlorobenzene 

Pesticides

Aldrin Dieldrin PCB-1254 

Alpha-BHC Alpha-Endosulfan PCB-1221 

Beta-BHC Beta-Endosulfan PCB-1232 

Gamma-BHC Endosulfan Sulfate PCB-1248 

Delta-BHC Endrin PGB-1260 

Chlordane Endrin Aldehyde PCB-1016 

4,4'-DDT Heptachlor Toxaphene 

4,4'-DDE Heptachlor Epoxide 

4,4'-DDD PCB-1242 
EPA Form 3510-2F (Rev. 1-92) I - 11 

Table 2F-4 

Hazardous Substances 

Toxic Pollutant 

Asbestos 

Hazardous Substances 

Acetaldehyde Dinitrobenzene Napthenic acid 

Allyl alcohol Diquat Nitrotoluene 

Allyl chloride Disulfoton Parathion 

Amyl acetate Diuron Phenolsulfonate 

Aniline . Epichlorohydrin Phosgene 

Benzonitrile Ethion Propargite 

Benzyl chloride Ethylene diamine Propylene oxide 

Butyl acetate Ethylene dibromide Pyrethrins 

Butylamine Formaldehyde Quinoline 

Carbaryl Furfural Resorcinol 

Carbofuran Guthion Stronthium 

Carbon disulfide Isoprene Strychnine 

Chlorpyrifos Isopropanolamine Styrene 

Coumaphos Kelthane 2,4,5-T (2,4,5-Trichlorophenoxyacetic 

acid) 

Cresol Kepone TDE (Tetrachlorodiphenyl ethane) 

Crotonaldehyde Malathion 2,4,5-TP [2-(2,4,5-Trichlorophenoxy) 

propanoic acid] 

Cyclohexane Mercaptodimethur Trichlorofan 

2,4-D (2,4-Dichlorophenoxyacetic 

acid) 

Methoxychlor Triethylamine 

Diazinon Methyl mercaptan Trimethylamine 

Dicamba Methyl methacrylate Uranium 

Dichlobenil Methyl parathion Vanadium 

Dichlone Mevinphos Vinyl acetate 

2,2-Dichloropropionic acid Mexacarbate Xylene 

Dichlorvos Monoethyl amine Xylenol 

Diethyl amine Monomethyl amine Zirconium 

Dimethyl amine Naled 
Disclaimer 

This is an updated PDF document that allows you to type your information 

directly into the form, print it, and save the completed form. 

Note: This form can be viewed and saved only using Adobe Acrobat Reader 

version 7.0 or higher, or if you have the full Adobe Professional version. 

Instructions: 

1. Type in your information 

2. Save file (if desired) 

3. Print the completed form 

4. Sign and date the printed copy 

5. Mail it to the directed contact. 
 EPA Form 3510-2S (Rev. 1-99) Page 1 of 23 

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

FORM

2S 

NPDES

NPDES FORM 2S APPLICATION OVERVIEW

PRELIMINARY INFORMATION 

This page is designed to indicate whether the applicant is to complete Part 1 or Part 2. Review each category, 

and then complete Part 1 or Part 2, as indicated. For purposes of this form, the term “you” refers to the 

applicant. “This facility” and “your facility” refer to the facility for which application information is submitted.

FACILITIES INCLUDED IN ANY OF THE FOLLOWING CATEGORIES MUST COMPLETE PART 2 

(PERMIT APPLICATION INFORMATION).

1. Facilities with a currently effective NPDES permit. 

 

2. Facilities which have been directed by the permitting authority to submit a full permit application at this time. 

ALL OTHER FACILITIES MUST COMPLETE PART 1 (LIMITED BACKGROUND INFORMATION).
EPA Form 3510-2S (Rev. 1-99) Page 2 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

PART 1: LIMITED BACKGROUND INFORMATION

This part should be completed only by “sludge-only” facilities - that is, facilities that do not currently have, and are not applying for, an 

NPDES permit for a direct discharge to a surface body of water. 

For purposes of this form, the term “you” refers to the applicant. “This facility” and “your facility” refer to the facility for which application 

information is submitted. 

1. Facility Information.

a. Facility name __________________________________________________________________ 

b. Mailing Address __________________________________________________________________ 

 __________________________________________________________________ 

 

c. Contact person __________________________________________________________________ 

 Title __________________________________________________________________ 

 Telephone number __________________________________________________________________ 

d. Facility Address (not P.O. B ox) __________________________________________________________________ 

 __________________________________________________________________ 

 

e. Indicate the type of facility 

_________ Publicly owned treatment works (POTW) _________ Privately owned treatment works 

_________ Federally owned treatment works _________ Blending or treatment operation 

_________ Surface disposal site _________ Sewage sludge incinerator 

 _________ Other (describe) __________________________________________________________________ 

2. Applicant Information.

a. Applicant name __________________________________________________________________ 

b. Mailing Address __________________________________________________________________ 

 __________________________________________________________________ 

 

c. Contact person __________________________________________________________________ 

 Title __________________________________________________________________ 

 Telephone number __________________________________________________________________ 

d. Is the applicant the owner or operator (or both) of this facility? 

 ______ owner ______ operator 

e. Should correspondence regarding this permit be directed to the facility or the applicant? 

 ______ facility ______ applicant 
EPA Form 3510-2S (Rev. 1-99) Page 3 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

3. Sewage Sludge Amount. Provide the total dry metric tons per latest 365 day period of sewage sludge handled under the following practices: 

a. Amount generated at the facility ________________ dry metric tons 

b. Amount received from off site ________________ dry metric tons 

c. Amount treated or blended on site ________________ dry metric tons 

d. Amount sold or given away in a bag or other container for application to the land ________________ dry metric tons 

e. Amount of bulk sewage sludge shipped off site for treatment or blending ________________ dry metric tons 

f. Amount applied to the land in bulk form ________________ dry metric tons 

g. Amount placed on a surface disposal site ________________ dry metric tons 

h. Amount fired in a sewage sludge incinerator ________________ dry metric tons 

i. Amount sent to a municipal solid waste landfill ________________ dry metric tons 

j. Amount used or disposed by another practice ________________ dry metric tons 

 Describe ____________________________________________________________________ 

4. Pollutant Concentrations. Using the table below or a separate attachment, provide existing sewage sludge monitoring data for the pollutants for 

which limits in sewage sludge have been established in 40 CFR part 503 for this facility's expected use or disposal practices. If available, base 

data on three or more samples taken at least one month apart and no more than four and one-half years old. 

POLLUTANT CONCENTRATION 

(mg/kg dry weight) 

ANALYTICAL METHOD DETECTION LEVEL FOR ANALYSIS 

ARSENIC 

CADMIUM 

CHROMIUM 

COPPER 

LEAD 

MERCURY 

MOLYBDENUM 

NICKEL 

SELENIUM 

ZINC 

5. Treatment Provided At Your Facility.

a. Which class of pathogen reduction does the sewage sludge meet at your facility? 

 _______ Class A _______ Class B _______ Neither or unknown 

b. Describe, on this form or another sheet of paper, any treatment processes used at your facility to reduce pathogens in sewage sludge: 

 ___________________________________________________________________________________________________________ 

 ___________________________________________________________________________________________________________ 

 ___________________________________________________________________________________________________________ 

 ___________________________________________________________________________________________________________ 

 ___________________________________________________________________________________________________________ 
EPA Form 3510-2S (Rev. 1-99) Page 4 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

c. Which vector attraction reduction option is met for the sewage sludge at your facility? 

 _______ Option 1 (Minimum 38 percent reduction in volatile solids) 

 _______ Option 2 (Anaerobic process, with bench-scale demonstration) 

 _______ Option 3 (Aerobic process, with bench-scale demonstration) 

 _______ Option 4 (Specific oxygen uptake rate for aerobically digested sludge) 

 _______ Option 5 (Aerobic processes plus raised temperature) 

 _______ Option 6 (Raise pH to 12 and retain at 11.5) 

 _______ Option 7 (75 percent solids with no unstabilized solids) 

 _______ Option 8 (90 percent solids with unstabilized solids) 

 _______ Option 9 (Injection below land surface) 

 _______ Option 10 (Incorporation into soil within 6 hours) 

 _______ Option 11 (Covering active sewage sludge unit daily) 

 _______ None or unknown 

d. Describe, on this form or another sheet of paper, any treatment processes used at your facility to reduce vector attraction properties of 

sewage sludge: 

 _______________________________________________________________________________________________ 

 _______________________________________________________________________________________________ 

6. Sewage Sludge Sent to Other Facilities. Does the sewage sludge from your facility meet the Table 1 ceiling concentrations, the Table 3 

pollutant concentrations, Class A pathogen requirements, and one of the vector attraction options 1-8? 

 _______ Yes _______ No 

 

If yes, go to question 8 (Certification). 

If no, is sewage sludge from your facility provided to another facility for treatment, distribution, use, or disposal? 

______ Yes ______ No 

If no, go to question 7 (Use and Disposal Sites). 

If yes, provide the following information for the facility receiving the sewage sludge: 

a. Facility name _______________________________________________________________________ 

b. Mailing address _______________________________________________________________________ 

 _______________________________________________________________________ 

c. Contact person _______________________________________________________________________ 

 Title _______________________________________________________________________ 

 Telephone number _______________________________________________________________________ 

d. Which activities does the receiving facility provide? (Check all that apply) 

 ______ Treatment or blending ______ Sale or give-away in bag or other container 

 ______ Land application ______ Surface disposal 

 ______ Incineration ______ Other (describe): 

_______________________________________________________________________________________________

_______________________________________________________________________________________________ 
EPA Form 3510-2S (Rev. 1-99) Page 5 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

7. Use and Disposal Sites. Provide the following information for each site on which sewage sludge from this facility is used or disposed: 

a. Site name or number ______________________________________________________________________ 

b. Contact person ______________________________________________________________________ 

 Title ______________________________________________________________________ 

 Telephone ______________________________________________________________________ 

c. Site location (Complete 1 or 2) 

 1. Street or Route # ______________________________________________________________________ 

 County ______________________________________________________________________ 

 City or Town ______________________ State __________________ Zip ___________________ 

 2. Latitude ____________________ Longitude____________________ 

d. Site type (Check all that apply) 

 ____ Agricultural ____ Lawn or home garden ____ Forest 

 ____ Surface disposal ____ Public Contact ____ Incineration 

 ____ Reclamation ____ Municipal Solid Waste Landfill ____ Other (describe): ________________________________ 

8. Certification. Sign the certification statement below. (Refer to instructions to determine who is an officer for purposes of this certification.) 

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with the 

system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person 

or persons who manage the system or those persons directly responsible for gathering the information, the information 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 and official title ________________________________________________________ 

Signature ________________________________________________________ 

Telephone number ________________________________________________________ 

Date signed ________________________________________________________ 

SEND COMPLETED FORMS TO:
EPA Form 3510-2S (Rev. 1-99) Page 6 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

PART 2: PERMIT APPLICATION INFORMATION

Complete this part if you have an effective NPDES permit or have been directed by the permitting authority to submit a full permit 

application at this time. In other words, complete this part if your facility has, or is applying for, an NPDES permit. 

For purposes of this form, the term “you” refers to the applicant. “This facility” and “your facility” refer to the facility for which application 

information is submitted. 

APPLICATION OVERVIEW — SEWAGE SLUDGE USE OR DISPOSAL INFORMATION

Part 2 is divided into five sections (A-E). Section A pertains to all applicants. The applicability of Sections B, C, D, and E depends on your 

facility's sewage sludge use or disposal practices. The information provided on this page indicates which sections of Part 2 to fill out. 

1. SECTION A: GENERAL INFORMATION.

Section A must be completed by all applicants 

2. SECTION B: GENERATION OF SEWAGE SLUDGE OR PREPARATION OF A MATERIAL DERIVED FROM SEWAGE SLUDGE.

Section B must be completed by applicants who either: 

1) Generate sewage sludge, or 

2) Derive a material from sewage sludge. 

3. SECTION C: LAND APPLICATION OF BULK SEWAGE SLUDGE.

Section C must be completed by applicants who either: 

1) Apply sewage to the land, or 

2) Generate sewage sludge which is applied to the land by others. 

NOTE: Applicants who meet either or both of the two above criteria are exempted from this requirement if all sewage sludge from their facility 

falls into one of the following three categories: 

1) The sewage sludge from this facility meets the ceiling and pollutant concentrations, Class A pathogen reduction requirements, and one of 

vector attraction reduction options 1-8, as identified in the instructions, or 

2) The sewage sludge from this facility is placed in a bag or other container for sale or give-away for application to the land, or 

3) The sewage sludge from this facility is sent to another facility for treatment or blending. 

4. SECTION D: SURFACE DISPOSAL

Section D must be completed by applicants who own or operate a surface disposal site. 

5. SECTION E: INCINERATION

Section E must be completed by applicants who own or operate a sewage sludge incinerator. 

 
EPA Form 3510-2S (Rev. 1-99) Page 7 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

A. GENERAL INFORMATION

All applicants must complete this section. 

A.1. Facility Information.

a. Facility name __________________________________________________________________ 

b. Mailing Address ___________________________________________________________________ 

 ___________________________________________________________________ 

c. Contact person ___________________________________________________________________ 

 Title ___________________________________________________________________ 

 Telephone number ___________________________________________________________________ 

d. Facility Address (not P.O. Box) ___________________________________________________________________ 

 ___________________________________________________________________ 

e. Is this facility a Class I sludge management facility? ______ Yes ______ No 

f. Facility design flow rate: ______ mgd 

g. Total population served: ___________ 

h. Indicate the type of facility: 

 ______ Publicly owned treatment works (POTW) ______ Privately owned treatment works 

 ______ Federally owned treatment works ______ Blending or treatment operation 

 ______ Surface disposal site ______ Sewage sludge incinerator 

 ______ Other (describe) __________________________________________________________________ 

A.2. Applicant Information. If the applicant is different from the above, provide the following: 

a. Applicant name ___________________________________________________________________ 

b. Mailing Address ___________________________________________________________________ 

 ___________________________________________________________________ 

c. Contact person ___________________________________________________________________ 

 Title ___________________________________________________________________ 

 Telephone number ___________________________________________________________________ 

d. Is the applicant the owner or operator (or both) of this facility? 

 ______ owner ______ operator 

e. Should correspondence regarding this permit should be directed to the facility or the applicant. 

 ______ facility ______ applicant 
EPA Form 3510-2S (Rev. 1-99) Page 8 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

A.3. Permit Information.

a. Facility's NPDES permit number (if applicable): _______________________________________________________ 

b. List, on this form or an attachment, all other Federal, State, and local permits or construction approvals received or applied for that regulate 

this facility's sewage sludge management practices: 

 Permit Number Type of Permit 

 _______________________ __________________________ 

 _______________________ __________________________ 

 _______________________ __________________________ 

A.4. Indian Country. Does any generation, treatment, storage, application to land, or disposal of sewage sludge from this facility occur in Indian

Country? 

______Yes ______No If yes, describe: ______________________________________________________________ 

________________________________________________________________________________________________________ 

A.5. Topographic Map. Provide a topographic map or maps (or other appropriate map(s) if a topographic map is unavailable) that show the 

following information. Map(s) should include the area one mile beyond all property boundaries of the facility: 

a. Location of all sewage sludge management facilities, including locations where sewage sludge is stored, treated, or disposed. 

b. Location of all wells, springs, and other surface water bodies, listed in public records or otherwise known to the applicant within 1/4 mile of 

the facility property boundaries. 

A.6. Line Drawing. Provide a line drawing and/or a narrative description that identifies all sewage sludge processes that will be employed during the 

term of the permit, including all processes used for collecting, dewatering, storing, or treating sewage sludge, the destination(s) of all liquids and 

solids leaving each unit, and all methods used for pathogen reduction and vector attraction reduction. 

A.7. Contractor Information.

Are any operational or maintenance aspects of this facility related to sewage sludge generation, treatment, use or disposal the responsibility of a 

contractor? ______Yes ______No 

If yes, provide the following for each contractor (attach additional pages if necessary): 

a. Name ___________________________________________________________________ 

b. Mailing Address ___________________________________________________________________ 

 ___________________________________________________________________ 

 

c. Telephone Number ___________________________________________________________________ 

d. Responsibilities of contractor ___________________________________________________________________ 

 ____________________________________________________________________________________________________ 
EPA Form 3510-2S (Rev. 1-99) Page 9 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

A.8. Pollution Concentrations: Using the table below or a separate attachment, provide sewage sludge monitoring data for the pollutants for which 

limits in sewage sludge have been established in 40 CFR Part 503 for this facility's expected use or disposal practices. All data must be based 

on three or more samples taken at least one month apart and must be no more than four and one-half years old. 

POLLUTANT CONCENTRATION 

(mg/kg dry weight) 

ANALYTICAL METHOD DETECTION LEVEL FOR ANALYSIS 

ARSENIC 

CADMIUM 

CHROMIUM 

COPPER 

LEAD 

MERCURY 

MOLYBDENUM 

NICKEL 

SELENIUM 

ZINC 

A.9. Certification. Read and submit the following certification statement with this application. Refer to the instructions to determine who is an officer 

for purposes of this certification. Indicate which parts of Form 2S you have completed and are submitting: 

______ Part 1 Limited Background Information packet Part 2 Permit Application Information packet: 

______ Section A (General Information) 

______ Section B (Generation of Sewage Sludge or Preparation 

of a Material Derived from Sewage Sludge) 

______ Section C (Land Application of Bulk Sewage Sludge) 

______ Section D (Surface Disposal) 

______ Section E (Incineration) 

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with 

the system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the 

person or persons who manage the system or those persons directly responsible for gathering the information, the information 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 and official title _____________________________________________________________________________ 

Signature ___________________________________________ Date signed _______________________ 

Telephone number _____________________________________________________________________________ 

Upon request of the permitting authority, you must submit any other information necessary to assess sewage sludge use or disposal practices at 

your facility or identify appropriate permitting requirements. 

SEND COMPLETED FORMS TO: 
EPA Form 3510-2S (Rev. 1-99) Page 10 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

B. GENERATION OF SEWAGE SLUDGE OR PREPARATION OF 

A MATERIAL DERIVED FROM SEWAGE SLUDGE

Complete this section if your facility generates sewage sludge or derives a material from sewage sludge. 

B.1. Amount Generated On Site.

Total dry metric tons per 365-day period generated at your facility: _______________________ dry metric tons 

B.2. Amount Received from Off Site. If your facility receives sewage sludge from another facility for treatment, use, or disposal, provide the 

following information for each facility from which sewage sludge is received. If you receive sewage sludge from more than one facility, attach 

additional pages as necessary. 

a. Facility name ___________________________________________________________________ 

b. Mailing Address ___________________________________________________________________ 

 ___________________________________________________________________ 

 

c. Contact person ___________________________________________________________________ 

 Title ___________________________________________________________________ 

 Telephone number ___________________________________________________________________ 

d. Facility Address (not P.O. Box) ___________________________________________________________________ 

 ___________________________________________________________________ 

 

e. Total dry metric tons per 365-day period received from this facility: ______________________ dry metric tons 

f. Describe, on this form or on another sheet of paper, any treatment processes known to occur at the off-site facility, including blending 

activities and treatment to reduce pathogens or vector attraction characteristics. 

 ________________________________________________________________________________________________ 

 ________________________________________________________________________________________________ 

B.3. Treatment Provided At Your Facility.

a. Which class of pathogen reduction is achieved for the sewage sludge at your facility? 

 _______ Class A _______ Class B _______ Neither or unknown 

b. Describe, on this form or another sheet of paper, any treatment processes used at your facility to reduce pathogens in sewage sludge: 

 ________________________________________________________________________________________________ 

 ________________________________________________________________________________________________ 

c. Which vector attraction reduction option is met for the sewage sludge at your facility? 

 _______ Option 1 (Minimum 38 percent reduction in volatile solids) 

 _______ Option 2 (Anaerobic process, with bench-scale demonstration) 

 _______ Option 3 (Aerobic process, with bench-scale demonstration) 

 _______ Option 4 (Specific oxygen uptake rate for aerobically digested sludge) 

 _______ Option 5 (Aerobic processes plus raised temperature) 

 _______ Option 6 (Raise pH to 12 and retain at 11.5) 

 _______ Option 7 (75 percent solids with no unstabilized solids) 

 _______ Option 8 (90 percent solids with unstabilized solids) 

 _______ None or unknown 
EPA Form 3510-2S (Rev. 1-99) Page 11 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

B.3. Treatment Provided At Your Facility. (con’t)

d. Describe, on this form or another sheet of paper, any treatment processes used at your facility to reduce vector attraction properties of 

sewage sludge: 

 _________________________________________________________________________________________________ 

 _________________________________________________________________________________________________ 

e. Describe, on this form or another sheet of paper, any other sewage sludge treatment or blending activities not identified in (a) - (d) above: 

 _________________________________________________________________________________________________ 

 _________________________________________________________________________________________________ 

Complete Section B.4 if sewage sludge from your facility meets the ceiling concentrations in Table 1 of 40 CFR 503.13, the pollutant 

concentrations in Table 3 of §503.13, the Class A pathogen reduction requirements in §503.32(a), and one of the vector attraction reduction 

requirements in § 503.33(b)(1)-(8) and is land applied. Skip this section if sewage sludge from your facility does not meet all of these 

criteria. 

B.4. Preparation of Sewage Sludge Meeting Ceiling and Pollutant Concentrations, Class A Pathogen Requirements, and One of Vector 

Attraction Reduction Options 1-8.

a. Total dry metric tons per 365-day period of sewage sludge subject to this section that is applied to the land: ___________ dry metric tons 

b. Is sewage sludge subject to this section placed in bags or other containers for sale or give-away for application to the land? 

 _______Yes _______No 

Complete Section B.5. if you place sewage sludge in a bag or other container for sale or give-away for land application. Skip this section if 

the sewage sludge is covered in Section B.4. 

B.5. Sale or Give-Away in a Bag or Other Container for Application to the Land.

a. Total dry metric tons per 365-day period of sewage sludge placed in a bag or other container at your facility for sale or give-away for 

application to the land: _________________________ dry metric tons 

b. Attach, with this application, a copy of all labels or notices that accompany the sewage sludge being sold or given away in a bag or other 

container for application to the land. 

Complete Section B.6 if sewage sludge from your facility is provided to another facility that provides treatment or blending. This section 

does not apply to sewage sludge sent directly to a land application or surface disposal site. Skip this section if the sewage sludge is 

covered in Sections B.4 or B.5. If you provide sewage sludge to more than one facility, attach additional pages as necessary. 

B.6. Shipment Off Site for Treatment or Blending.

a. Receiving facility name _______________________________________________________________________ 

b. Mailing address _______________________________________________________________________ 

 _______________________________________________________________________ 

 

c. Contact person _______________________________________________________________________ 

 Title _______________________________________________________________________ 

 Telephone number _______________________________________________________________________ 

d. Total dry metric tons per 365-day period of sewage sludge provided to receiving facility: ______________________ 
EPA Form 3510-2S (Rev. 1-99) Page 12 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

B.6. Shipment Off Site for Treatment or Blending. (con’t)

e. Does the receiving facility provide additional treatment to reduce pathogens in sewage sludge from your facility? ____ Yes ____ No 

 Which class of pathogen reduction is achieved for the sewage sludge at the receiving facility? 

 ______ Class A ______ Class B ______ Neither or unknown 

 Describe, on this form or another sheet of paper, any treatment processes used at the receiving facility to reduce pathogens in sewage 

 sludge: 

_________________________________________________________________________________________________ 

 _________________________________________________________________________________________________ 

f. Does the receiving facility provide additional treatment to reduce vector attraction characteristics of the sewage sludge? 

 ______Yes ______No 

 Which vector attraction reduction option is met for the sewage sludge at the receiving facility? 

______ Option 1 (Minimum 38 percent reduction in volatile solids) 

______ Option 2 (Anaerobic process, with bench-scale demonstration) 

______ Option 3 (Aerobic process, with bench-scale demonstration) 

______ Option 4 (Specific oxygen uptake rate for aerobically digested sludge) 

______ Option 5 (Aerobic processes plus raised temperature) 

______ Option 6 (Raise pH to 12 and retain at 11.5) 

______ Option 7 (75 percent solids with no unstabilized solids) 

______ Option 8 (90 percent solids with unstabilized solids) 

______ None 

Describe, on this form or another sheet of paper, any treatment processes used at the receiving facility to reduce vector attraction 

properties of sewage sludge. 

_________________________________________________________________________________________________ 

_________________________________________________________________________________________________ 

g. Does the receiving facility provide any additional treatment or blending activities not identified in (c) or (d) above? ____ Yes ____ No 

 If yes, describe, on this form or another sheet of paper, the treatment or blending activities not identified in (c) or (d) above: 

 _________________________________________________________________________________________________ 

 _________________________________________________________________________________________________ 

h. If you answered yes to (e), (f), or (g), attach a copy of any information you provide the receiving facility to comply with the “notice and 

necessary information” requirement of 40 CFR 503.12(g). 

i. Does the receiving facility place sewage sludge from your facility in a bag or other container for sale or give-away for application to the 

land? ______ Yes ______ No 

 If yes, provide a copy of all labels or notices that accompany the product being sold or given away. 

Complete Section B.7 if sewage sludge from your facility is applied to the land, unless the sewage sludge is covered in: 

• Section B.4 (it meets Table 1 ceiling concentrations, Table 3 pollutant concentrations, Class A pathogen requirements, and one of 

vector attraction reduction options 1-8); or

• Section B.5 (you place it in a bag or other container for sale or give-away for application to the land); or

• Section B.6 (you send it to another facility for treatment or blending). 

B.7. Land Application of Bulk Sewage Sludge.

a. Total dry metric tons per 365-day period of sewage sludge applied to all land application sites: _______________ dry metric tons 
EPA Form 3510-2S (Rev. 1-99) Page 13 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

B.7. Land Application of Bulk Sewage Sludge. (con’t)

b. Do you identify all land application sites in Section C of this application? ______ Yes ______ No 

 If no, submit a copy of the land application plan with application (see instructions). 

c. Are any land application sites located in States other than the State where you generate sewage sludge or derive a material from sewage 

sludge? _______ Yes _______ No 

 If yes, describe, on this form or another sheet of paper, how you notify the permitting authority for the States where the land application 

 sites are located. Provide a copy of the notification. 

 ___________________________________________________________________________________________________ 

 ___________________________________________________________________________________________________ 

Complete Section B.8 if sewage sludge from your facility is placed on a surface disposal site. 

B.8. Surface Disposal.

a. Total dry metric tons of sewage sludge from your facility placed on all surface disposal sites per 365-day period: ________ dry metric tons 

b. Do you own or operate all surface disposal sites to which you send sewage sludge for disposal? 

 _______ Yes _______ No 

 If no, answer B.8.c through B.8.f for each surface disposal site that you do not own or operate. If you send sewage sludge to more than 

one such surface disposal site, attach additional pages as necessary. 

c. Site name or number _______________________________________________________________________ 

d. Contact person _______________________________________________________________________ 

 Title _______________________________________________________________________ 

 Telephone number _______________________________________________________________________ 

 Contact is _________Site owner _________Site operator 

e. Mailing address _______________________________________________________________________ 

 _______________________________________________________________________ 

f. Total dry metric tons of sewage sludge from your facility placed on this surface disposal site per 365-day period: ________ dry metric tons 

Complete Section B.9 if sewage sludge from your facility is fired in a sewage sludge Incinerator. 

B.9. Incineration.

a. Total dry metric tons of sewage sludge from your facility fired in all sewage sludge incinerators per 365-day period: ______ dry metric tons 

b. Do you own or operate all sewage sludge incinerators in which sewage sludge from your facility is fired? ______ Yes ______ No 

 If no, complete B.9.c through B.9.f for each sewage sludge incinerator that you do not own or operate. If you send sewage sludge to more 

than one such sewage sludge incinerator, attach additional pages as necessary. 

c. Incinerator name or number: ___________________________________________________________________ 

d. Contact person: ___________________________________________________________________ 

 Title: ___________________________________________________________________ 

 Telephone number: ___________________________________________________________________ 

 Contact is: _________ Incinerator owner _________ Incinerator operator 
EPA Form 3510-2S (Rev. 1-99) Page 14 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

B.9. Incineration. (con’t)

e. Mailing address: ___________________________________________________________________ 

 ___________________________________________________________________ 

 

f. Total dry metric tons of sewage sludge from your facility fired in this sewage sludge incinerator per 365-day period: ______ dry metric tons 

Complete Section B.10 if sewage sludge from this facility is placed on a municipal solid waste landfill. 

B.10. Disposal in a Municipal Solid Waste Landfill. Provide the following information for each municipal solid waste landfill on which sewage 

sludge from your facility is placed. If sewage sludge is placed on more than one municipal solid waste landfill, attach additional pages as 

necessary. 

 a. Name of landfill ___________________________________________________________________ 

 b. Contact person ___________________________________________________________________ 

 Title ___________________________________________________________________ 

 Telephone number ___________________________________________________________________ 

 Contact is _________ Landfill owner _________ Landfill operator 

 c. Mailing address ___________________________________________________________________ 

 ___________________________________________________________________ 

 

 d. Location of municipal solid waste landfill: 

 Street or Route # __________________________________________________________________ 

 County __________________________________________________________________ 

 City or Town ____________________________ State ___________ Zip _______________ 

 e. Total dry metric tons of sewage sludge from your facility placed in this municipal solid waste landfill per 365-day period:

_______________________ dry metric tons 

 f. List, on this form or an attachment, the numbers of all other Federal, State, and local permits that regulate the operation of this 

municipal solid waste landfill. 

 Permit Number Type of Permit 

 _______________________ __________________________ 

 _______________________ __________________________ 

 _______________________ __________________________ 

 g. Submit, with this application, information to determine whether the sewage sludge meets applicable requirements for disposal of 

sewage sludge in a municipal solid waste landfill (e.g., results of paint filter liquids test and TCLP test) 

 h. Does the municipal solid waste landfill comply with applicable criteria set forth in 40 CFR Part 258? 

 _______ Yes _______ No 
EPA Form 3510-2S (Rev. 1-99) Page 15 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

C. LAND APPLICATION OF BULK SEWAGE SLUDGE

Complete Section C for sewage sludge that is applied to the land, unless any of the following conditions apply: 

• The sewage sludge meets the Table 1 ceiling concentrations, the Table 3 pollutant concentrations, Class A pathogen 

requirements, and one of vector attraction reduction options 1-8 (fill out B.4 Instead); or 

• The sewage sludge is sold or given away in a bag or other container for application to the land (fill out B.5 Instead); or 

• You provide the sewage sludge to another facility for treatment or blending (fill out B.6 instead). 

Complete Section C for every site on which the sewage sludge that you reported in Section B.7 is applied. 

C.1. Identification of Land Application Site.

a. Site name or number _______________________________________________________________________ 

b. Site location (Complete 1 and 2). 

 1. Street or Route # _______________________________________________________________________ 

 County _______________________________________________________________________ 

 City or Town ___________________________ State ___________ Zip _____________________ 

 2. Latitude ____________________ Longitude ____________________ 

 

 Method of latitude/longitude determination 

 ______ USGS map ______ Field survey ______ Other 

c. Topographic map. Provide a topographic map (or other appropriate map if a topographic map is unavailable) that shows the site location. 

C.2. Owner Information.

a. Are you the owner of this land application site? ______ Yes ______ No 

b. If no, provide the following information about the owner: 

 Name __________________________________________________________________________ 

 Telephone number __________________________________________________________________________ 

 Mailing Address __________________________________________________________________________ 

 __________________________________________________________________________ 

 

C.3. Applier Information.

a. Are you the person who applies, or who is responsible for application of, sewage sludge to this land application site? 

 ______ Yes ______ No 

b. If no, provide the following information for the person who applies: 

 Name __________________________________________________________________________ 

 Telephone number __________________________________________________________________________ 

 Mailing Address __________________________________________________________________________ 

 __________________________________________________________________________ 

C.4. Site Type: Identify the type of land application site from among the following. 

______ Agricultural land ______ Forest ______ Public contact site 

______ Reclamation site ______ Other. Describe: _________________________________________ 
EPA Form 3510-2S (Rev. 1-99) Page 16 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

C.5. Crop or Other Vegetation Grown on Site.

a. What type of crop or other vegetation is grown on this site? 

 _______________________________________________________________________________________________ 

b. What is the nitrogen requirement for this crop or vegetation? 

_______________________________________________________________________________________________ 

C.6. Vector Attraction Reduction.

Are any vector attraction reduction requirements met when sewage sludge is applied to the land application site? 

______ Yes ______ No 

If yes, answer C.6.a and C.6.b; 

 a. Indicate which vector attraction reduction option is met: 

 ______ Option 9 (Injection below land surface) 

 ______ Option 10 (Incorporation into soil within 6 hours) 

 b. Describe, on this form or another sheet of paper, any treatment processes used at the land application site to reduce vector attraction 

properties of sewage sludge: 

 ____________________________________________________________________________________________ 

 ____________________________________________________________________________________________ 

Complete Question C.7 only if the sewage sludge applied to this site since July 20, 1993, is subject to the cumulative pollutant loading 

rates (CPLRs) in 40 CFR 503.13(b)(2). 

C.7. Cumulative Loadings and Remaining Allotments.

a. Have you contacted the permitting authority in the State where the bulk sewage sludge subject to CPLRs will be applied, to ascertain 

whether bulk sewage sludge subject to CPLRs has been applied to this site on or since July 20, 1993? ______ Yes ______ No 

 If no, sewage sludge subject to CPLRs may not be applied to this site. 

 If yes, provide the following information: 

 Permitting authority ___________________________________________________________________ 

 Contact Person __________________________________________________________________ 

 Telephone number ___________________________________________________________________ 

b. Based upon this inquiry, has bulk sewage sludge subject to CPLRs been applied to this site since July 20, 1993? 

 ______ Yes ______ No 

 If no, skip C.7.c. 

 
EPA Form 3510-2S (Rev. 1-99) Page 17 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

c. Provide the following information for every facility other than yours that is sending, or has sent, bulk sewage sludge to CPLRs to this site 

since July 20, 1993. If more than one such facility sends sewage sludge to this site, attach additional pages as necessary. 

 Facility name _______________________________________________________________________ 

 Mailing Address _______________________________________________________________________ 

 _______________________________________________________________________ 

 

 Contact person _______________________________________________________________________ 

 Title _______________________________________________________________________ 

 Telephone number _______________________________________________________________________ 
EPA Form 3510-2S (Rev. 1-99) Page 18 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

D. SURFACE DISPOSAL

Complete this section if you own or operate a surface disposal site. 

Complete Sections D.1 - D.5 for each active sewage sludge unit. 

D.1. Information on Active Sewage Sludge Units.

a. Unit name or number: ______________________________________________________________________ 

b. Unit location (Complete 1 and 2). 

 1. Street or Route # __________________________________________________________________________ 

 County __________________________________________________________________________ 

 City or Town __________________________ State _____________ Zip _______________________ 

 2. Latitude____________________ Longitude____________________ 

 

 Method of latitude/longitude determination: ______ USGS map ______ Field survey ______ Other 

c. Topographic map. Provide a topographic map (or other appropriate map if a topographic map is unavailable) that shows the site location. 

d. Total dry metric tons of sewage sludge placed on the active sewage sludge unit per 365-day period: __________________ dry metric tons 

e. Total dry metric tons of sewage sludge placed on the active sewage sludge unit over the life of the unit: _______________ dry metric tons 

f. Does the active sewage sludge unit have a liner with a maximum hydraulic conductivity of 1 × 10-7 cm/sec? ______ Yes ______ No 

 If yes, describe the liner (or attach a description): 

 ______________________________________________________________________________________________ 

 ______________________________________________________________________________________________ 

g. Does the active sewage sludge unit have a leachate collection system? ______ Yes ______ No 

 If yes, describe the leachate collection system (or attach a description). Also describe the method used for leachate disposal and provide 

the numbers of any Federal, State, or local permit(s) for leachate disposal: 

 _____________________________________________________________________________________________ 

 _____________________________________________________________________________________________ 

h. If you answered no to either D.1.f. or D.1.g., answer the following question: 

 Is the boundary of the active sewage sludge unit less than 150 meters from the property line of the surface disposal site? 

 ______ Yes ______ No 

 If yes, provide the actual distance in meters: __________________________ 

 Provide the following information: 

 Remaining capacity of active sewage sludge unit, in dry metric tons: _______________________ dry metric tons 

 Anticipated closure date for active sewage sludge unit, if known: _______________________ (MM/DD/YYYY) 

 Provide, with this application, a copy of any closure plan that has been developed for this active sewage sludge unit. 
EPA Form 3510-2S (Rev. 1-99) Page 19 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

D.2. Sewage Sludge from Other Facilities. Is sewage sent to this active sewage sludge unit from any facilities other than your facility? 

 ______ Yes ______ No 

If yes, provide the following information for each such facility. If sewage sludge is sent to this active sewage sludge unit from more than one 

such facility, attach additional pages as necessary. 

a. Facility name _______________________________________________________________________ 

b. Mailing Address _______________________________________________________________________ 

 _______________________________________________________________________ 

 

c. Contact person _______________________________________________________________________ 

 Title _______________________________________________________________________ 

 Telephone number _______________________________________________________________________ 

d. Which class of pathogen reduction is achieved before sewage sludge leaves the other facility? 

 ______ Class A ______ Class B ______ None or unknown 

e. Describe, on this form or another sheet of paper, any treatment processes used at the other facility to reduce pathogens in sewage sludge: 

 ___________________________________________________________________________________________ 

 ___________________________________________________________________________________________ 

f. Which vector attraction reduction option is met for the sewage sludge at the receiving facility? 

______ Option 1 (Minimum 38 percent reduction in volatile solids) 

______ Option 2 (Anaerobic process, with bench-scale demonstration) 

______ Option 3 (Aerobic process, with bench-scale demonstration) 

______ Option 4 (Specific oxygen uptake rate for aerobically digested sludge) 

______ Option 5 (Aerobic processes plus raised temperature) 

______ Option 6 (Raise pH to 12 and retain at 11.5) 

______ Option 7 (75 percent solids with no unstabilized solids) 

______ Option 8 (90 percent solids with unstabilized solids) 

______ None or unknown 

g. Describe, on this form or another sheet of paper, any treatment processes used at the receiving facility to reduce vector attraction 

properties of sewage sludge 

 _____________________________________________________________________________________________ 

 _____________________________________________________________________________________________ 

h. Describe, on this form or another sheet of paper, any other sewage sludge treatment activities performed by the other facility that are not 

identified in (d) - (g) above: 

 _____________________________________________________________________________________________ 

 _____________________________________________________________________________________________ 

D.3. Vector Attraction Reduction

a. Which vector attraction option, if any, is met when sewage sludge is placed on this active sewage sludge unit? 

______ Option 9 (Injection below and surface) 

______ Option 10 (Incorporation into soil within 6 hours) 

______ Option 11 (Covering active sewage sludge unit daily) 
EPA Form 3510-2S (Rev. 1-99) Page 20 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

D.3. Vector Attraction Reduction. (con’t)

b. Describe, on this form or another sheet of paper, any treatment processes used at the active sewage sludge unit to reduce vector attraction 

properties of sewage sludge: 

 _____________________________________________________________________________________________ 

 _____________________________________________________________________________________________ 

D.4. Ground-Water Monitoring.

a. Is ground-water monitoring currently conducted at this active sewage sludge unit, or are ground-water monitoring data otherwise available 

for this active sewage sludge unit? 

 ______ Yes ______ No 

If yes, provide a copy of available ground-water monitoring data. Also, provide a written description of the well locations, the approximate 

depth to ground-water, and the ground-water monitoring procedures used to obtain these data. 

 _____________________________________________________________________________________________ 

 _____________________________________________________________________________________________ 

b. Has a ground-water monitoring program been prepared for this active sewage sludge unit? ______ Yes ______ No 

 

 If yes, submit a copy of the ground-water monitoring program with this permit application. 

c. Have you obtained a certification from a qualified ground-water scientist that the aquifer below the active sewage sludge unit has not been 

contaminated? ______ Yes ______ No 

If yes, submit a copy of the certification with this permit application. 

D.5. Site-Specific Limits. Are you seeking site-specific pollutant limits for the sewage sludge placed on the active sewage sludge unit? 

 ______ Yes ______ No 

If yes, submit information to support the request for site-specific pollutant limits with this application. 

 
EPA Form 3510-2S (Rev. 1-99) Page 21 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

E. INCINERATION

Complete this section if you fire sewage sludge in a sewage sludge incinerator. 

Complete this section once for each incinerator in which you fire sewage sludge. If you fire sewage sludge in more than one sewage 

sludge incinerator, attach additional copies of this section s necessary. 

E.1. Incinerator Information.

a. Incinerator name or number: _______________________________________________________________________ 

b. Incinerator location (Complete 1 and 2). 

 1. Street or Route # _______________________________________________________________________ 

 County _______________________________________________________________________ 

 City or Town _____________________________ State ______________ Zip __________________ 

 2. Latitude____________________ Longitude____________________ 

 

 Method of latitude/longitude determination: ______ USGS map ______ Field survey ______ Other 

 

E.2. Amount Fired. Dry metric tons per 365-day period of sewage sludge fired in the sewage sludge incinerator: _____________ dry metric tons 

E.3. Beryllium NESHAP.

a. Is the sewage sludge fired in this incinerator “beryllium-containing waste,” as defined in 40 CFR Part 61.31? ______ Yes ______ No 

 Submit, with this application, information, test data, and description of measures taken that demonstrate whether the sewage sludge 

incinerated is beryllium-containing waste, and will continue to remain as such. 

b. If the answer to (a) is yes, submit with this application a complete report of the latest beryllium emission rate testing and documentation 

of ongoing incinerator operating parameters indicating that the NESHAP emission rate limit for beryllium has been and will continue to be 

met. 

E.4. Mercury NESHAP.

a. How is compliance with the mercury NESHAP being demonstrated? 

 ______ Stack testing (if checked, complete E.4.b) 

 ______ Sewage sludge sampling (if checked, complete E.4.c) 

b. If stack testing is conducted, submit the following information with this application: 

 A complete report of stack testing and documentation of ongoing incinerator operating parameters indicating that the incinerator has met, 

and will continue to meet, the mercury NESHAP emission rate limit. 

 Copies of mercury emission rate tests for the two most recent years in which testing was conducted. 

c. If sewage sludge sampling is used to demonstrate compliance, submit a complete report of sewage sludge sampling and documentation of 

ongoing incinerator operating parameters indicating that the incinerator has met, and will continue to meet the mercury NESHAP emission 

rate limit. 

E.5. Dispersion Factor.

a. Dispersion factor, in micrograms/cubic meter per gram/second: __________________________ 

b. Name and type of dispersion model: _________________________________________________ 

c. Submit a copy of the modeling results and supporting documentation with this application. 
EPA Form 3510-2S (Rev. 1-99) Page 22 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

E.6. Control Efficiency.

a. Control efficiency, in hundredths, for the following pollutants: 

 Arsenic: _______ Chromium: _______ Nickel: _______ 

 Cadmium: _______ Lead: _______ 

 

b. Submit a copy of the results or performance testing and supporting documentation (including testing dates) with this application. 

E.7. Risk Specific Concentration for Chromium.

a. Risk specific concentration (RSC) used for chromium, in micrograms per cubic meter: ______________ 

b. Which basis was used to determine the RSC? 

 ____Table 2 in 40 CFR 503.43 

 ____Equation 6 in 40 CFR 503,43 (site-specific determination) 

c. If Table 2 was used, identify the type of incinerator used as the basis: 

 ____Fluidized bed with wet scrubber 

 ____Fluidized bed with wet scrubber and wet electrostatic precipitator 

 ____Other types with wet scrubber 

 ____Other types with wet scrubber and wet electrostatic precipitator 

d. If Equation 6 was used, provide the following: 

 Decimal fraction of hexavalent chromium concentration to total chromium concentration in stack exit gas: _____________ 

 Submit results of incinerator stack tests for hexavalent and total chromium concentrations, including date(s) of test, with this application. 

E.8. Incinerator Parameters

a. Do you monitor Total Hydrocarbons (THC) in the sewage sludge incinerator's exit gas? Yes No 

 Do you monitor Carbon Monoxide (CO) in the sewage sludge incinerator's exit gas? Yes No 

b. Incinerator type: _______________________ 

c. Incinerator stack height, in meters: ______________________ 

 Indicate whether value submitted is: ______ Actual stack height ______ Creditable stack height 

E.9. Performance Test Operating Parameters

a. Maximum Performance Test Combustion Temperature: _______________________________ 

b. Performance test sewage sludge feed rate, in dry metric tons/day: _______________________ 

 indicate whether value submitted is: 

 ______ Average use ______ Maximum design 

 Submit, with this application, supporting documents describing how the feed rate was calculated. 

c. Submit, with this application, information documenting the performance test operating parameters for the air pollution control device(s) used 

for this sewage sludge incinerator. 
EPA Form 3510-2S (Rev. 1-99) Page 23 of 23

FACILITY NAME AND PERMIT NUMBER: Form Approved 1/14/99 

OMB Number 2040-0086 

E.10. Monitoring Equipment. List the equipment in place to monitor the following parameters: 

a. Total hydrocarbons or carbon monoxide: _________________________________________________________ 

b. Percent oxygen: _________________________________________________________ 

c. Moisture content: _________________________________________________________ 

d. Combustion temperature: _________________________________________________________ 

e. Other: _________________________________________________________ 

E.11. Air Pollution Control Equipment. Submit, with this application, a list of all air pollution control equipment used with this sewage sludge 

incinerator.

_________________________________________________________________________________________________ 

_________________________________________________________________________________________________ 

_________________________________________________________________________________________________ 

_________________________________________________________________________________________________ 
NPDES FORM 2S Additional Information 

Additional Information, if provided, will appear on the following pages.
EPA FORM 3510-6 (Revised 09-2008) Page 1 of 7 

NPDES 

FORM 

3510-6

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, DC 20460 

NOTICE OF INTENT (NOI) FOR STORMWATER DISCHARGES ASSOCIATED WITH 

INDUSTRIAL ACTIVITY UNDER THE NPDES MULTI-SECTOR GENERAL PERMIT

Form Approved. 

OMB No. 2040-0086 

Submission of this completed Notice of Intent (NOI) constitutes notice that the operator identified in Section B of this form requests authorization to discharge pollutants 

to waters of the United States from the facility or site identified in Section C under EPA’s NPDES Stormwater Multi-Sector General Permit (MSGP) for industrial 

stormwater. Submission of this NOI constitutes your notice to EPA that the facility identified in Section C of this form meets the eligibility conditions of Part 1.1 of the 

MSGP. Please read and make sure you comply with all eligibility requirements, including the requirement to prepare a stormwater pollution prevention plan. Refer to the 

instructions at the end of this form to complete your NOI. 

A. Permit 

Number: R (see Appendix C of the MSGP for the list of 

eligible permit numbers) 

Tracking Number (EPA Use 

Only): 

B. Facility Operator Information 

1. Name: 

2. IRS Employer Identification Number (EIN): – 

3. Mailing Address: 

a. Street: 

b. City: c. State: d. Zip Code: - 

e. Phone: - - f. Fax 

(optional): 

 - - g. E-mail:_________________________________________ 

C. Facility Information 

1. Facility Name: 

2. Have stormwater discharges from your site been covered previously under an NPDES permit? YES NO 

a. If yes, provide the Tracking Number if you had coverage under EPA’s MSGP 2000 

or the NPDES permit number if you had coverage under an EPA individual permit. 

b.1 If no, was your facility in operation and discharging stormwater prior to October 30, 2005? YES NO 

b.2 If no to C.2.b.1, did your facility commence discharging after October 30, 2005 and before January 5, 2009? YES NO 

3. Location Address: 

a. Street 

b. City: 

c. County or similar government subdivision: d. State: e. Zip Code: - 

f. Latitude: (use 

any one of the 

three formats 

provided.) 

1. ___ ___° ___ ___ ́ ___ ___ ̋ N (degrees, minutes, seconds) 

2. ___ ___° ___ ___. ___ ___ ́ N (degrees, minutes, decimal) 

3. ___ ___. ___ ___ ___ ___° N ( degrees decimal) 

g. Longitude: 

(use any of 

these 3 

formats) 

1. ___ ___ ___° ___ ___ ́ ___ ___ ̋ W (degrees, minutes, seconds) 

2. ___ ___ ___° ___ ___. ___ ___ ́ W (degrees, minutes, decimal) 

3. ___ ___ ___. ___ ___ ___ ___° W (degrees decimal) 

h. Lat/Long Data Source: USGS topographic map EPA web site GPS Other: _______________________________________________ 

 If you used a USGS topographic map, what was the scale? __________________________________________________________________________ 

4. Estimated area of industrial activity at your site exposed to stormwater: (acres) 

5. Is this a federal facility? YES NO 

6. Is your facility located on Indian Country lands? YES NO 

 If yes, name of reservation, or if not part of a reservation, put “Not Applicable:” ___________________________________________________________ 
EPA FORM 3510-6 (Revised 09-2008) Page 2 of 7 

D. Discharge information 

1. Does your facility discharge stormwater into a Municipal Separate Storm Sewer System (MS4)? YES NO 

 If yes, name of MS4 operator: ___________________________________________________________________________________________________

2. Receiving Waters and Wetlands (Note: If additional space is needed for this question, fill out Attachment 1.) 

a. What is the name(s) of your receiving water(s) If you answered yes to question D.2.b, then answer the following three questions: 

that receive stormwater directly and/or through an 

MS4)? 

If your receiving water is impaired then identify the 

name of the impaired segment, if applicable, in 

parentheses following the receiving water name. 

b. Are any of your 

discharges directly 

into any segment of 

an “impaired” 

water? 

b.1. What pollutant(s) are causing the 

impairment? 

b.2. Are the 

pollutant(s) causing 

the impairment 

present in your 

discharge? 

b.3. Has a TMDL 

been completed for 

the pollutant(s) 

causing the 

impairment? 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

3. Water Quality Standards (for new dischargers only) 

a. Are any of your discharges into any portion of a receiving water designated by the state or tribal authority under its antidegradation policy as a Tier 2 (or Tier 

2.5) water (water quality exceeds levels necessary to support propagation of fish, shellfish, and wildlife and recreation in and on the water)? YES NO 

b. Has the receiving water(s) been designated by the state or tribal authority under its antidegradation policy as a Tier 3 water (Outstanding Natural Resource 

Water)? YES NO 

4. Federal Effluent Limitation Guidelines and Sector-Specific Requirements 

a. Are you requesting permit coverage for any stormwater discharges subject to effluent limitation guidelines? YES NO 

b. If yes, which effluent limitation guidelines apply to your stormwater discharges? 

40 CFR Part/Subpart Eligible Discharges Affected MSGP Sector Check if Applicable 

Part 411, Subpart C Runoff from material storage piles at cement manufacturing facilities E 

Part 418 Subpart A 

Runoff from phosphate fertilizer manufacturing facilities that comes 

into contact with any raw materials, finished product, by-products or 

waste products (SIC 2874) 

C 

Part 423 Coal pile runoff at steam electric generating facilities O 

Part 429, Subpart I Discharges resulting from spray down or intentional wetting of logs at 

wet deck storage areas A 

Part 436, Subpart B, C, or D Mine dewatering discharges at crushed stone mines, construction 

sand and gravel mines, or industrial sand mines J 

Part 443, Subpart A Runoff from asphalt emulsion facilities D 

Part 445, Subparts A & B Runoff from hazardous waste and non-hazardous waste landfills K, L 

c. If you are a Sector S (Air Transportation) facility, do you anticipate using more than 100,000 gallons of glycol-based deicing/anti-icing chemicals and/or 100 tons 

or more of urea on an average annual basis? YES NO 

5. Identify the 4-digit Standard Industrial Classification (SIC) code or 2-letter Activity Code that best represents the products produced or services rendered for which 

your facility is primarily engaged, as defined in MSGP: 

Primary SIC Code: OR Primary Activity Code 

6. Identify the applicable sector(s) and subsector(s) of industrial activity, including co-located industrial activity, for which you are requesting permit coverage: 

a. Sector Subsector b. Sector Subsector c. Sector Subsector

d. Sector Subsector e. Sector Subsector f. Sector Subsector

7.a. Is your site presently inactive and unstaffed? YES NO 

b1. If yes, is your site expected to be inactive and unstaffed for the entire permit term? YES NO 

b2. If you select “no” in 7.b1 above, then indicate the length of time that you expect your facility to be inactive and unstaffed _______________________________ 
EPA FORM 3510-6 (Revised 09-2008) Page 3 of 7 

E. Stormwater Pollution Prevention Plan (SWPPP) Contact Information 

1a. SWPPP Contact Name: 

b. Phone: - - Ext. c. E-mail: 

2. URL of SWPPP (if applicable): __________________________________________________________________________________________________________ 

F. Endangered Species Protection 

1. Using the instructions in Appendix E of the MSGP, under which criterion listed in Part 1.1.4.5 are you eligible for coverage under this permit? 

A B C D E F 

2. If you select criterion E from Part 1.1.4.5: 

 a. What federally-listed species or federally-designated critical habitat are in your “action area?”_______________________________________________________ 

 __________________________________________________________________________________________________________________________________ 

 b. List the pollutants expected to be present in your discharge ________________________________________________________________________________ 

 __________________________________________________________________________________________________________________________________ 

 c. If you are an existing discharger, do you have effluent monitoring data from EPA’s MSGP 2000, or another previous NPDES permit?  YES  NO 

c.1 If no, why not? No monitoring required for my sector Inactive/unstaffed site Other _______________________________ 

c.2 Do you have any other data characterizing pollutants in your stormwater (describe)? ____________________________________________________ 

c.3 If you have benchmark monitoring data, did you exceed any of the applicable benchmarks? YES NO 

c.4 Did you exceed any applicable effluent limitation guideline or cause or contribute to an exceedance of a State or Tribal water quality standard? YES NO 

c.5 If you answered “yes” to either question F.2.c.3 or F.2.c.4 above, for what pollutant(s)? _________________________________________________________ 

d. Attach documentation supporting criterion E eligibility. Documentation should address species and habitat listed in F.2.a and the potential effects of pollutants listed 

in F.2.b (including any monitoring data for these pollutants) on the listed species and habitat. 

3. If you select criterion F from Part 1.1.4.5, provide the operator’s NPDES 

Tracking Number under which you are certifying eligibility: 

G. Historic Preservation 

Using the instructions in Appendix F of the MSGP, under which criterion listed in Part 1.1.4.6 are you eligible for coverage under this permit? 

A B C D 

H. Certifier Name and Title 

I certify under penalty of law that I meet the eligibility conditions of this permit and that this document and all attachments were prepared under my direction or 

supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of 

the person or persons who manage the system, or those persons directly responsible for gathering the information, I certify that the information submitted is, to the best 

of my knowledge and belief, true, accurate, and complete. I certify that I am aware that there are significant penalties for submitting false information, including the 

possibility of fines and imprisonment for knowing violations. 

Print Name: 

Title: 

Signature: _________________________________________________________________________________ Date: 

E-mail: 

NOI Preparer (Complete if NOI was prepared by someone other than the certifier)

Prepared by: 

Organization: 

Phone: - - Ext. E-mail: 
EPA FORM 3510-6 (Revised 09-2008) Page 4 of 7 

Attachment 1. (Fill in as necessary if more space is required for D.2 a-e) 

a. What is the name(s) of your receiving water(s) If you answered yes to question D.2.b, then answer the following three questions: 

that receive stormwater from your facility (directly 

and/or through an MS4)? 

If your receiving water is impaired then identify the 

name of the impaired segment, if applicable, in 

parentheses following the receiving water name. 

b. Are any of your 

discharges directly 

into any segment of 

an “impaired” 

water? 

b.1. What pollutant(s) are causing the 

impairment? 

b.2. Are the 

pollutant(s) causing 

the impairment 

present in your 

discharge? 

b.3. Has a TMDL 

been completed for 

the pollutant(s) 

causing the 

impairment? 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 

 YES NO YES NO YES NO 
EPA FORM 3510-6 (Revised 09-2008) Page 5 of 7 

Instructions for Completing the Notice of Intent for Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the Multi-Sector General Permit (MSGP) 

Who Must File a Notice of Intent with EPA? 

Under section 402(p) of the Clean Water Act (CWA) and regulations at 40 CFR 

Part 122, stormwater discharges associated with industrial activity are prohibited to 

waters of the United States unless authorized under a National Pollutant Discharge 

Elimination System (NPDES) permit. You can obtain coverage under the MSGP by 

submitting a completed NOI if you operate a facility: 

• that is located in a jurisdiction where EPA is the permitting authority, listed in 

Appendix C of the MSGP, 

• that discharges stormwater associated with industrial activities, identified in 

Appendix D of the MSGP, 

• that meets the eligibility requirements in Part 1.1 of the permit, 

• that develops a stormwater pollution prevention plan (SWPPP) in accordance 

with Part 5 of the MSGP; and 

• that installs and implements control measures in accordance with Part 2 to 

meet numeric and non-numeric effluent limits. 

If you are unsure if you need an NPDES stormwater permit, contact your EPA or 

State NPDES stormwater permit program. Contacts are listed at 

www.epa.gov/npdes/stormwatercontacts. 

One NOI must be submitted for each facility or site for which you are seeking 

permit coverage. You do not need to submit separate NOIs for each type of 

industrial activity present at your facility, provided your SWPPP covers all activities. 

When to File the NOI Form 

Do not file your NOI until you have obtained and thoroughly read a copy of the 

MSGP. A copy of the MSGP is located on the EPA website 

(www.epa.gov/npdes/stormwater/msgp). The MSGP describes procedures to 

ensure your eligibility, prepare your SWPPP, install and implement appropriate 

stormwater control measures, and complete the NOI form questions – all of which 

must be done before you sign the NOI certification statement attesting to the 

accuracy and completeness of your NOI. You will also need a copy of the MSGP 

once you have obtained coverage so that you can comply with the implementation 

requirements of the permit. 

Where to File the NOI Form 

EPA encourages you to complete the NOI form electronically via the Internet. 

EPA’s Electronic Notice of Intent System (eNOI) can be found at 

www.epa.gov/npdes/enoi. Filing electronically is the fastest way to obtain permit 

coverage and help ensure that your NOI is complete. If you choose not to file 

electronically, you must send the NOI to one of the addresses listed below. 

NOIs sent regular mail:

Stormwater Notice Processing Center (4203M) 

USEPA 

1200 Pennsylvania Avenue, NW 

Washington, DC 20460 

NOIs sent overnight/express mail:

Stormwater Notice Processing Center 

EPA East Building, Rm. 7420 

1201 Constitution Avenue, NW 

Washington, DC 20004 

202-564-9545 

If you have questions, please contact EPA’s Stormwater Notice Processing 

Center toll free at (866) 352-7755. 

• If you file a paper NOI, please submit the original with a signature in ink – 

Do Not Send Copies. Also, faxed copies will not be accepted. 

• Your SWPPP does not need to be submitted for review unless specifically 

requested by EPA or as otherwise required in Part 9 of the MSGP (State, 

Territory, and Tribal requirements). You must keep a copy of your SWPPP 

on-site or otherwise make it available to facility personnel responsible for 

implementing provisions of the permit.

Completing the NOI Form 

To complete this form, type or print in uppercase letters in the appropriate areas 

only. Please make sure you complete all questions. Make sure you make a 

photocopy for your records before you send the completed original form to the 

address above. You may also use this paper form as a checklist for the information 

you will need when filing an NOI electronically via EPA’s eNOI system. 

Section A. Permit Number 

Appendix C of the MSGP 2008 contains a list of geographic areas covered by 

the permit. If your facility is located in one of the listed areas, include the appropriate 

permit number in this section. (For example, if you facility is located in 

Massachusetts, and not on Indian Lands, you would write MAR050000 in this 

space.) If your facility is located in an area not covered by the MSGP, please 

contact your EPA Region, state or territorial NPDES stormwater coordinator (see 

www.epa.gov/npdes/stormwatercontacts for a list of contacts). 

Section B. Facility Operator Information 

1. Provide the legal name of the person, firm, public organization or any other 

public entity that operates the facility described in this application. An operator of 

a facility is a legal entity that controls the operation of the facility. 

2. Provide the Employer Identification Number (EIN from the Internal Revenue 

Service (IRS)), commonly referred to as your taxpayer ID number. If the operator 

does not have an EIN, enter “NA” in the space provided. 

3. Provide the operator’s mailing address, telephone number, fax number 

(optional), and email address. Correspondence will be sent to this address. 

Section C. Facility Information 

1. Enter the facility’s official or legal name. Unless the name of your facility has 

changed, please use the same name provided on prior NOIs or permit 

applications. You can use EPA’s NOI Search website 

(www.epa.gov/npdes/noisearch) to view your previous NOI. 

2. Indicate if industrial stormwater discharges from your facility were previously 

covered by an NPDES permit. 

2a.If your facility was covered by EPA’s MSGP-2000, please include the tracking 

number that you received in your confirmation letter or email from EPA’s 

Stormwater Notice Processing Center. You can find the tracking number 

assigned to your previous NOI on EPA’s NOI Search website 

(www.epa.gov/npdes/noisearch). 

2b1.If your facility was not previously covered by an NPDES permit and discharged 

industrial stormwater, then indicate if it was in operation before October 30, 

2005 and not covered under the MSGP 2000. If you select “yes” to this question 

then you have a 30 day waiting period before you are authorized to discharge. 

2b2.If you select “no” in C.2.b.1, then indicate if your facility discharged stormwater 

between October 30, 2005 and January 5, 2009. If you select “yes” to this 

NOI Submittal Deadlines/Discharge Authorization Dates 

Category NOI Deadline Discharge Authorization Date1

Existing Dischargers - in 

operation as of October 

30, 2005 and authorized 

for coverage under 

MSGP 2000. 

No later than January 

5, 2009. 

30 days after EPA posts your 

NOI. Your authorization under 

the MSGP 2000 is automatically 

continued until you have been 

granted coverage under this 

permit or an alternative permit, 

or coverage is otherwise 

terminated. 

New Dischargers or 

New Sources - have 

commenced discharging 

between October 30, 

2005 and January 5, 

2009. 

As soon as possible 

but no later than 

January 5, 2009. 

30 days after EPA posts your 

NOI. 

New Dischargers or 

New Sources - 

commence discharging 

after January 5, 2009. 

A minimum of 60 days 

prior to commencing 

operation of the facility, 

or a minimum of 30 

days if your SWPPP is 

posted on the Internet 

during this period and 

the Internet address 

(i.e., URL) to your 

SWPPP is provided on 

the NOI form. 

If you post your SWPPP on the 

Internet, 30 days after EPA 

posts your NOI. Otherwise, 60 

days after EPA posts your NOI. 

New Owner/Operator of 

Existing Discharger - 

transfer of ownership 

and/or operation of a 

facility whose discharge 

is authorized under this 

permit 

A minimum of 30 days 

prior to date that the 

transfer will take place 

to the new 

owner/operator. 

30 days after EPA posts your 

NOI. 

Other Eligible 

Dischargers - in 

operation prior to 

October 30, 2005 but 

not covered under the 

MSGP 2000 or another 

NPDES permit. 

Immediately, to 

minimize the time 

discharges from the 

facility will continue to 

be unauthorized. 

If you post your SWPPP on the 

Internet, 30 days after EPA 

posts your NOI. Otherwise, 60 

days after EPA posts your NOI. 

1 Based on a review of your NOI or other information, EPA may delay your 

authorization for further review, notify you that additional effluent limitations are 

necessary, or may deny coverage under this permit and require submission of an 

application for an individual NPDES permit, as detailed in MSGP Part 1.6. In these 

instances, EPA will notify you in writing of the delay or the request for submission of an 

individual NPDES permit application. EPA will post these NOIs on its website at 

www.epa.gov/npdes/enoi. 
EPA FORM 3510-6 (Revised 09-2008) Page 6 of 7 

question then you have a 30 day waiting period before you are authorized to 

discharge. If you select “no” to this question and you post your SWPPP on the 

Internet and provide EPA the URL in E.2, then you have a 30 day waiting period 

before you are authorized to discharge. If you select “no” to this question, but do 

not post your SWPPP on the Internet and therefore do not answer E.2, then you 

have a 60 day waiting period before you are authorized to discharge. 

3.a-e. Enter the street address, including city, state, zip code, county or similar 

government subdivision of the actual physical location of the facility. Do not use 

a P.O. Box. 

3.f-g. Provide the facility latitude and longitude in one of three formats: (1) degrees, 

minutes, seconds; (2) degrees, minutes, decimal; or(3) degrees decimal. You 

can obtain your facility’s latitude and longitude though Global Positioning 

System (GPS) receivers, U.S. Geological Survey (USGS) quadrangle or 

topographic maps, and EPA’s web-based siting-tools, among other methods. 

Refer to www.epa.gov/npdes/stormwater/msgp for guidance on the use of these 

methods. For consistency, EPA requests you take measurements from the 

location of your facility’s stormwater outfall. Outfalls are locations where the 

stormwater exits the facility, including pipes, ditches, swales, and other 

structures that transport stormwater. If there is more than one outfall present, 

measure at the primary outfall (i.e., the outfall with the largest volume of 

stormwater discharge associated with industrial activity). 

3.h. Identify the data source that you used to determine the facility latitude and 

longitude. If you did not use a USGS quadrangle or topographic map, the EPA 

website, or GPS receivers, then select “Other” and write the method used on 

the line provided. If you used a USGS quadrangle or topographic map, write the 

map scale on the line provided. Scale should be identified on the map. 

4. Enter the estimated area of industrial activity at your site exposed to 

stormwater, in acres. 

5. Indicate if the facility is considered a “federal facility” - Federal facilities include 

any buildings, installations, structures, land, public works, equipment, aircraft, 

vessels, and other vehicles and property, owned or leased by the federal 

government. 

6. Indicate whether the facility is located in Indian Country, and, if so, provide the 

name of the reservation, if applicable. 

Section D. Discharge Information 

1. Indicate whether stormwater from your site will be discharged into a municipal 

separate storm sewer system (MS4). An MS4 is a conveyance or system of 

conveyances, including roads with drainage systems, municipal streets, catch 

basins, storm drains, curbs and gutters, ditches and man-made channels, 

owned or operated by a state, city, town, borough, county, parish, district, 

association or other public body, used to collect or convey stormwater. If you 

check “Yes” then identify the name of the MS4 operator on the line provided. If 

you are uncertain of the MS4 operator, contact your local government for that 

information. MS4s are different than combined sewers, which are designed to 

convey both stormwater and sanitary wastewater. Discharges to combined 

sewers do not require an NPDES permit but may be subject to other CWA 

requirements (contact the combined sewer operator for more information). 

2. Enter information regarding your discharge. If additional space is needed fill out 

Attachment 1. 

2a. Indicate in column “a” of the table the name(s) of the receiving water(s) into 

which stormwater from your facility will discharge. Also provide in parentheses 

the name of the impaired water (and segment, if applicable) into which your 

stormwater is discharged. If you identified more than on receiving water for your 

facility, indicate the first receiving water and complete question 2b and 2.b.1-3 (if 

applicable), before entering the next receiving water. The EPA’s Water Locator 

Tool can help you identify the closest receiving water to your facility 

(www.epa.gov/npdes/msgp). Your receiving water may be a lake, stream, river, 

ocean, wetland or other waterbody, and may or may not be located adjacent to 

your facility. Your stormwater may discharge directly to the receiving water or 

indirectly via a storm sewer system, an open drain or ditch, or other conveyance 

structure. Do NOT list a man-made conveyance, such as a storm sewer system, 

as your receiving water. Indicate the first receiving water your stormwater 

discharge enters. For example, if your discharge enters a storm sewer system, 

that empties into Trout Creek, which flows into Pine River, your receiving water is 

Trout Creek, because it is the first waterbody your discharge will reach. Similarly, 

a discharge into a ditch that feeds Spring Creek should be identified as “Spring 

Creek” since the ditch is a manmade conveyance. If you discharge into a 

municipal separate storm sewer system (MS4), you must identify the waterbody 

into which that portion of the storm sewer discharges. That information should be 

readily available from the operator of the MS4.

2b. Indicate in column “b” of the table whether you discharge directly to an impaired 

water (lake, stream segment, estuary, etc), listed as “impaired” under section 

303(d) of the Clean Water Act. Each state water quality agency maintains a list of 

waters that are impaired. Most state agencies publish these lists online. The 

EPA’s Water Locator Tool may also help you identify if the nearest receiving 

water is impaired (www.epa.gov/npdes/msgp). If you discharge into a stream 

segment that is upstream of a listed impaired water but which is not itself on the 

State’s impaired waters list, answer “no” to this question. In this case, 

requirements in the MSGP for discharges into impaired waters do not apply to 

you, unless notified otherwise by EPA. 

Answer the following three questions only if you answered “Yes” to D 2.b: 

2b1. Provide the pollutant(s) listed as causing the impairment in the water identified 

in D.2.b.1 above. Enter each pollutant individually on a separate row in the 

table. 

2b2. Out of the pollutant(s) that you identified in D.2.b.1 above, indicate which 

pollutants you believe will be present in your discharge. If you do not expect the 

pollutant(s) to be in your discharge, then select “no.” 

2b3.Indicate the pollutant(s) that have a Total Maximum Daily Load (TMDL) for the 

impaired stream segment that you identified in D.2.b.2 above. Check with your 

state water quality agency for lists of waters with approved or established 

TMDLs. See www.epa.gov/npdes/msgp for more information. 

3. Water Quality Standards 

3a.If you selected “no” in C.2 indicating that stormwater discharges from your facility 

have not been previously covered under an NPDES permit, then you are 

considered a new discharger and must answer this question; otherwise you are 

considered an existing discharger and may skip this question. State water 

quality agencies are responsible for setting water quality standards for waters 

within the state’s boundaries. Check EPA’s website (www.epa.gov/npdes/msgp) 

to determine if the water(s) that you discharge into are designated as a “Tier 2 

(or Tier 2.5) water” (See Appendix A of the MSGP 2008 for definitions of “Tier 2 

water” and “Tier 2.5 water”). If you discharge into these waters, EPA may impose 

additional permit conditions to ensure that you do not violate the State’s 

antidegradation policy. 

3.b Idenitfy whether your receiving water is designated as a Tier 3 waterbody. Go to 

www.epa.gov/npdes/msgp for a list of Tier 3 waterbodies. Note that new 

discharges into designated Tier 3 waters are not eligible for coverage under the 

MSGP 2008. 

4. Federal Effluent Limitation Guidelines and Sector-Specific Requirements 

4.a-b. Depending on your industrial activities, your facility may be subject to effluent 

limitation guidelines which include additional effluent limits and monitoring 

requirements for your facility. Please review these requirements, described in 

Part 2.1.3 of the MSGP, and check any appropriate boxes on the NOI form. 

4.c. For Sector S facilities (Air Transportation), indicate whether you anticipate that 

the entire airport facility will use more than 100,000 gallons of glycol-based 

deicing/anti-icing chemicals and/or 100 tons or more of urea on an average 

annual basis. If so, additional effluent limits and monitoring conditions apply to 

your discharge (see Part 8 Sector S of the MSGP 2008). 

5. List the four-digit Standard Industrial Classification (SIC) code and/or two 

character activity code that best describes the primary industrial activities 

performed by your facility under which you are required to obtain permit 

coverage. Your primary industrial activity includes any activities performed onsite which are (1) identified by the facility’s one SIC code for which the facility is 

primarily engaged; and (2) included in the narrative descriptions of 40 CFR 

122.26(b)(14)(i), (iv), (v), or (vii), and (ix). See Appendix D of the MSGP for a 

complete list of SIC codes and activities codes. 

6. If your site has co-located industrial activities that are not identified as your 

primary industrial activity, identify the sector and subsector codes that describe 

these other industrial activities. For a complete list of sector and subsector 

codes, see Appendix D of the MSGP. 

7.a-b Indicate whether your facility is currently inactive and unstaffed. If so then 

indicate whether your facility will be inactive and unstaffed for the entire permit 

term, or if not, specify the specific length of time in units of days, weeks, months, 

or years (e.g. 3 months) that you expect the facility to be inactive and unstaffed.

Section E. Facility Contact Information and SWPPP Location 

1.a-c. Identify the name, telephone number, and email address of the person who 

will serve as a contact for EPA on issues related to stormwater management at 

your facility. This person should be able to answer questions related to 

stormwater discharges, the SWPPP, and other issues related to stormwater 

permit coverage, or have immediate access to individuals with that knowledge. 

This person does not have to be the facility operator, but should have intimate 

knowledge of stormwater management activities at the facility. 

2. If you are making your Stormwater Pollution Prevention Plan publicly available 

on a website provide the appropriate Internet URL address. (Please note that by 

posting your SWPPP on the web, you may qualify for a shortened authorization 

waiting period. See Table 1-2 of the MSGP for more information.) 

Section F. Endangered Species Protection 

1. Based on the instruction provided in Appendix E of the MSGP 2008, indicate 

which permit criterion (A,B,C,D,E, or F) listed in Part 1.1.4.5 you are using to 

satisfy your eligibility obligations for protection of endangered and threatened 

species, and designated critical habitat. 
EPA FORM 3510-6 (Revised 09-2008) Page 7 of 7 

2.a. If you select criterion E (not likely to adversely affect), list those federally-listed 

endangered or threatened species and any federally-listed designated critical 

habitat expected to exist in proximity to your facility. 

2.b List the pollutants that you expect to be present in your stormwater discharge. 

Include any pollutants that you may have included in D.2.b.3 above. 

2.c If you selected “yes” in C.2 then you are considered an existing discharger and 

must answer all the questions in F.2.c.1--5; otherwise you are considered a new 

discharger and may skip the questions under F.2.c. If you are an existing 

discharger who was previously covered under the MSGP 2000, indicate 

whether you have any previous effluent monitoring data. 

2.c1-2.If you select “No,” to F.2.c then indicate why you don’t have any data. Also 

indicate if you have any other data characterizing pollutants in your stormwater 

discharge. 

2.c.3. If you select “Yes,” to F.2.c then indicate whether you exceeded any 

benchmark. 

2.c.4 Indicate whether you have exceeded any applicable effluent limitation 

guideline, or caused or contributed to an exceedance of state or tribal water 

quality requirement(s). 

2.c.5. If you select “Yes” to F.2.c.3.and/or F.2.c.4 then indicate the pollutant 

parameters for which you exceeded the benchmark, applicable effluent 

limitation guideline, or State or Tribal water quality requirement(s). 

2.d. Attach your supporting rationale for your determination of the applicability of 

Criterion E for your facility (applies to both new and existing dischargers). Your 

documentation should address species and habitat listed in F.2.a and the 

potential effects of pollutants listed in F.2.b on the listed species and habitat. 

This should include consideration of any available data characterizing pollutants 

in your stormwater discharge, or in the discharge of similar facilities if data for 

you facility is not available, that may be of concern to listed species. 

3. If you select Criterion F (already addressed in another operator’s valid 

certification), provide the tracking number that the operator received in their 

confirmation letter or email from EPA’s NOI Processing Center (see Appendix 

E). You can find the tracking number assigned to your previous NOI on EPA’s 

NOI Search website (www.epa.gov/npdes/noisearch). An example where 

criterion F may apply includes airports where several individual airlines have 

applied for coverage under the MSGP, and the entire airport also has applied 

for or obtained coverage. If the airport has already certified under Appendix E, 

and that certification addresses any potential impacts from the individual 

airlines, then the airlines may reference the airport’s permit tracking number. 

Section G. Historic Preservation 

Based on the instruction provided in Appendix F of the MSGP 2008, indicate 

which permit criterion (A, B, C, or D) listed in Part 1.1.4.6 of the MSGP you used to 

satisfy your eligibility obligations for protection of historic properties. 

Section H. Certification 

Certification statement and signature (see Section B.11 of Appendix B of the 

MSGP for more information). Enter certifier’s printed name, title and email address. 

Sign and date the form. (CAUTION: An unsigned or undated NOI form will prevent 

the granting of permit coverage.) Federal statutes provide for severe penalties for 

submitting false information on this application form. Federal regulations require this 

application to be signed as follows: 

For a corporation: by a responsible corporate officer, which means: 

(i) president, secretary, treasurer, or vice-president of the corporation in charge of a 

principal business function, or any other person who performs similar policy or 

decision making functions for the corporation, or 

(ii) the manager of one or more manufacturing, production, or operating facilities, 

provided the manager is authorized to make management decisions which govern 

the operation of the regulated facility including having the explicit or implicit duty of 

making major capital investment recommendations, and initiating and directing other 

comprehensive measures to assure long term environmental compliance with 

environmental laws and regulations; the manager can ensure that the necessary 

systems are established or actions taken to gather complete and accurate 

information for permit application requirements; and where authority to sign 

documents has been assigned or delegated to the manager in accordance with 

corporate procedures; 

For a partnership or sole proprietorship: by a general partner or the proprietor; or 

For a municipal, State, Federal, or other public facility: by either a principal 

executive or ranking elected official. 

If the NOI was prepared by someone other than the certifier (for example, if the 

NOI was prepared by the facility SWPPP contact or a consultant for the certifier’s 

signature), include the name, organization, phone number and email address of the 

NOI preparer. 

Paperwork Reduction Act Notice 

Public reporting burden for this certification is estimated to average 3.7 hours per 

certification, including time for reviewing instructions, searching existing data 

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

the collection of information. Burden means the total time, effort, or financial 

resources expended by persons to generate, maintain, retain, or disclose to provide 

information to or for a Federal agency. This includes the time needed to review 

instructions; develop, acquire, install, and utilize technology and systems for the 

purposes of collecting, validating, and verifying information, processing and 

maintaining information, and disclosing and providing information; adjust the existing 

ways to comply with any previously applicable instructions and requirements; train 

personnel to be able to respond to a collection of information; search data sources; 

complete and review the collection of information; and transmit or otherwise disclose 

the information. An agency may not conduct or sponsor, and a person is not 

required to respond to, a collection of information unless it displays a currently valid 

OMB control number. Send comments regarding the burden estimate, any other 

aspect of the collection of information, or suggestions for improving this form, 

including any suggestions which may increase or reduce this burden to: Director, 

Office of Environmental Information Services, Collection Services Division (2823), 

USEPA, 1200 Pennsylvania Avenue, NW, Washington, DC 20460. Include the OMB 

control number of this form on any correspondence. Do not send the completed NOI 

form to this address. 
EPA FORM 3510-7 (Revised 09-2008) Page 1 of 2 

This Form Replaces Previous Form 2040-0086 (Please See Instructions Before Completing This Form)

NPDES 

FORM 

3510-7

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, DC 20460 

NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER A NPDES GENERAL PERMIT 

FOR STORMWATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY

Form Approved. 

OMB No. 2040-0086 

Submission of this Notice of Termination (NOT) constitutes notice that the party identified in Section B of this form is no longer authorized to discharge stormwater 

associated with industrial activity under the NPDES program for the facility identified in Section C of this form. All necessary information must be included on this form. 

Refer to the instructions at the end of this form. 

A. Permit Number: 

1. NPDES Permit Tracking Number: 

2. Reason for Termination (check one only): a.  You transferred operational control to another operator. 

 b.  You no longer have a stormwater discharge associated with industrial activity subject to regulation under the 

NPDES program, and you have already implemented necessary sediment and erosion controls as required by 

Part 2.1.2.5. 

 c.  You are a Sector G, H, or J facility and you have met the applicable termination requirements. 

 d.  You obtained coverage under an alternative NPDES permit. 

B. Facility Operator Information 

1. Name: 

2. IRS Employer Identification Number (EIN): – 

3. Mailing Address: 

a. Street: 

b. City: c. State: d. Zip Code: - 

e. Phone: - - f. Fax 

(optional): - - g. E-mail: ____________________________________________

C. Facility Information 

1. Facility Name: 

2. Location Address: 

a. Street 

b. City: 

c. County or similar government subdivision: d. State: e. Zip Code: - 

D. Certifier Name and Title 

I certify under penalty of law that I have met at least one of the reasons for terminating permit coverage listed in Section A.2 above. I understand that by submitting this 

Notice of Termination, I am no longer authorized to discharge stormwater associated with industrial activity under this general permit, and that discharging pollutants in 

stormwater associated with industrial activity to waters of the United States is unlawful under the Clean Water Act where the discharge is not authorized by a NPDES 

permit. I also understand that the submittal of this Notice of Termination does not release an operator from liability for any violations of this permit or the Clean Water 

Act. 

Print Name: 

Title: 

Signature: 

Date: 

E-mail: ___________________________________________________________________________________________ 
EPA FORM 3510-7 (Revised 09-2008) Page 2 of 2 

Instructions for Completing the Notice of Termination for Stormwater Discharges Associated with INDUSTRIAL ACTIVITY under the Multi-Sector General Permit 

(MSGP) 

Who May File Notice of Termination (NOT) Form 

Permittees currently covered by EPA’s NPDES Stormwater Multi-Sector General 

Permit may submit a Notice of Termination (NOT) form. You must submit an NOT 

within 30 days after one or more of the following conditions have been met: 

• a new owner or operator has assumed responsibility for the facility; or 

• you have ceased operations at the facility and there are not or no longer will be 

discharges of stormwater associated with industrial activity from the facility, and 

you have already implemented necessary sediment and erosion controls as 

required by Part 2.1.2.5; 

• you are a Sector G, H, or J facility and you have met the applicable termination 

requirements; or 

• you have obtained coverage under an individual or alternative general permit for 

all discharges required to be covered by an NPDES permit. 

See the MSGP Part 1.4 for more information. 

Where to File NOT form 

EPA encourages you to complete the NOT form online, via the Internet. The Electronic 

Notice of Intent System (eNOI) is found at www.epa.gov/npdes/eNOI. If you cannot 

access the electronic system, you must send the NOT to the address listed below. 

NOTs sent regular mail: 

Stormwater Notice of Termination (4203M) 

USEPA 

1200 Pennsylvania Avenue, NW 

Washington, D.C. 20460 

NOTs sent overnight/express 

Stormwater Notice of Termination 

US EPA East Building, Rm 7420 

1201 Constitution Avenue, NW 

Washington, D.C. 20004 

(202) 564-9545 

Completing the Form 

To complete this form, type or print in uppercase letters in the appropriate areas only. 

Please make sure you complete all questions. Make sure you make a photocopy for 

your records before you send the completed original form to the address above. 

Please use ink when you sign the original document – DO NOT send copies. If you 

have any questions about this form, you may call the EPA’s Stormwater Notice 

Processing Center at (866) 352-7755. 

Section A. Permit Information 

1. Enter the NPDES tracking number assigned by EPA’s Stormwater Notice Processing 

Center to the facility. If you do not know the tracking number, you can find the tracking 

number assigned to your previous NOI on EPA’s NOI Search website 

(www.epa.gov/npdes/noisearch). 

2. Indicate your reason for submitting this Notice of Termination by checking the 

appropriate box (see MSGP Part 1.4 for more information). 

Section B. Facility Operator Information 

1. Give the legal name of the person, firm, public organization, or any other entity that 

operates the facility described in this application. The operator of the facility is the 

legal entity which controls the facility’s operation, rather than the plant or site manager. 

Do not use a colloquial name. 

2-3. Enter the facility operator’s IRS Employer Identification Number (also know as the 

tax payer ID number). Enter the complete mailing address, email address and 

telephone number of the operator. This address will be used for any future 

correspondence between EPA and the facility operator. 

Section C. Facility Information 

1-2. Enter the facility’s official or legal name and complete address, including city, 

county or similar government subdivision, state, and ZIP code. 

Section D. Certification 

Certification statement and signature (see Section B.11 of Appendix B of the MSGP for 

more information). Enter certifier’s printed name, title and email address. Sign and 

date the form. Federal statutes provide for severe penalties for submitting false 

information on this application form. Federal regulations require this application to be 

signed as follows: 

For a corporation: by a responsible corporate officer, which means: (i) president, 

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

business function, or any other person who performs similar policy or decision making 

functions, or (ii) the manager of one or more manufacturing, production, or operating 

facilities employing more than 250 persons or having gross annual sales or 

expenditures exceeding $25 million (in second-quarter 1980 dollars), if authority to sign 

documents has been assigned or delegated to the manager in accordance with 

corporate procedures; 

For a partnership or sole proprietorship: by a general partner or the proprietor; or 

For a municipality State, Federal, or other facility: by either a principal executive office 

or ranking elected official. 

Paperwork Reduction Act Notice 

Public reporting burden for this application is estimated to average 0.5 hours per 

application, including time for reviewing instructions, searching existing data sources, 

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

collection of information. Send comments regarding the burden estimate, any other 

aspect of the collection of information, or suggestions for improving this form, including 

any suggestions which may increase or reduce this burden to: Director, Office of 

Environmental Information Services, Collection Services Division (2823), USEPA, 1200 

Pennsylvania Avenue, NW, Washington, DC 20460. Include the OMB control number 

of this form on any correspondence. Do not send the completed NOT form to this 

address. 
General Permit 

Appendix E - Notice of Intent Form and Instructions 

From the effective date of this permit, operators are to use the Notice of Intent Form 

contained in this Appendix to obtain permit coverage. 

Small and Large Construction Activities E-1 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N (degrees, minutes, decimal) 

This Form Replaces Form 3510-9 (8-98) 

Refer to the Following Pages for Instructions 

Form Approved OMB Nos. 2040-0188 and 2040-0211 

NPDES 

FORM 

United States Environmental Protection Agency 

Washington, DC 20460 

Notice of Intent (NOI) for Storm Water Discharges Associated with 

Construction Activity Under an NPDES General Permit 

Submission of this Notice of Intent (NOI) constitutes notice that the party identified in Section II of this form requests authorization to 

discharge pursuant to the NPDES Construction General Permit (CGP) permit number identified in Section I of this form. Submission of this 

NOI also constitutes notice that the party identified in Section II of this form meets the eligibility requirements of the CGP for the project 

identified in Section III of this form. Permit coverage is required prior to commencement of construction activity until you are eligible to 

terminate coverage as detailed in the CGP. To obtain authorization, you must submit a complete and accurate NOI form. Refer to the 

instructions at the end of this form. 

I. Permit Number 

II. Operator Information 

Name: 

IRS Employer Identification Number (EIN): – 

Mailing Address: 

Street: 

City: State: Zip Code: -

Phone: - - Fax (optional): - -

E-mail: 

III. Project/Site Information 

Project/Site Name: 

Project Street/Location: 

City: State: Zip Code: -

County or similar government subdivision: 

Latitude/Longitude (Use one of three possible formats, and specify method) 

Latitude 1. __ __° __ __ ́ __ __ ̋ N (degrees, minutes, seconds) 

2. __ __° __ __. __ __ ́

3. __ __. __ __ __ __° N ( degrees decimal) 

Longitude 1. __ __ __° __ __ ́ __ __ ̋ W (degrees, minutes, seconds) 

2. __ __ __° __ __. __ __ ́ W (degrees, minutes, decimal) 

3. __ __ __. __ __ __ __° W (degrees decimal) 

Method: U.S.G.S. topographic map EPA web site GPS Other: 

If you used a U.S.G.S. topographic map, what was the scale? ________________________________________________________ 

Project located in Indian Country? YES NO 

If yes, name of reservation, or if not part of a reservation, put “Not Applicable:” ___________________________________________ 

Estimated Project Start Date: / / Estimated Project Completion Date: / /

Month Day Year Month Day Year

Estimated Area to be Disturbed (to the nearest quarter acre): .

EPA FORM 3510-9 (Rev. 11/2008) Page 1 of 4
 

 

 

 

 

 

 

 

 

 

 

 

 

IV. SWPPP Information 

Has the SWPPP been prepared in advance of filing this NOI? YES NO 

Location of SWPP for Viewing: Address in Section II Address in Section III Other 

If other: 

SWPPP Street: 

City: State: Zip Code: -

SWPPP Contact Information (if different than that in Section II): 

Name: 

Phone: - - Fax (optional): - -

E-mail: 

V. Discharge Information 

Identify the name(s) of waterbodies to which you discharge. ___________________________________________________________________ 

___________________________________________________________________________________________________________________ 

Is this discharge consistent with the assumptions and requirements of applicable EPA approved or established TMDL(s)? YES NO 

VI. Endangered Species Protection 

Under which criterion of the permit have you satisfied your ESA eligibility obligations? 

A B C D E F 

If you select criterion F, provide permit tracking number of operator under which you are certifying eligibility: 

VII. Certification Information 

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a 

system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the 

person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted 

is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false 

information, including the possibility of fine and imprisonment for knowing violations. 

Print Name: 

Title:

Signature: _____________________________________________________________________________ Date:

E-mail: ________________________________________________________________________________ 

NOI Preparer (Complete if NOI was prepared by someone other than the certifier) 

Prepared by: 

Organization: 

Phone: - - Ext. E-mail:

EPA FORM 3510-9 (Rev. 11/2008) Page 2 of 4
 

 

 

 

 

 

 

 

Instructions for Completing EPA Form 3510-9 

Notice of Intent (NOI) for Storm Water Discharges Associated with
 

Construction Activity Under an NPDES General Permit 

NPDES Form Date This Form Replaces Form 3510-9 (8/98) Form Approved OMB Nos. 2040-0188 and 2040-0211 

Who Must File an NOI Form 

Under the provisions of the Clean Water Act, as amended (33 

U.S.C. 1251 et. seq.; the Act), federal law prohibits storm 

water discharges from certain construction activities to waters 

of the U.S. unless that discharge is covered under a National 

Pollutant Discharge Elimination System (NPDES) Permit. 

Operator(s) of construction sites where one or more acres are 

disturbed, smaller sites that are part of a larger common plan 

of development or sale where there is a cumulative 

disturbance of at least one acre, or any other site specifically 

designated by the Director, must submit an NOI to obtain 

coverage under an NPDES general permit. Each person, firm, 

public organization, or any other entity that meets either of the 

following criteria must file this form: (1) they have operational 

control over construction plans and specifications, including 

the ability to make modifications to those plans and 

specifications; or (2) they have day-to-day operational control 

of those activities at the project necessary to ensure 

compliance with SWPPP requirements or other permit 

conditions. If you have questions about whether you need an 

NPDES storm water permit, or if you need information to 

determine whether EPA or your state agency is the permitting 

authority, refer to www.epa.gov/npdes/stormwater/cgp or 

telephone the Storm Water Notice Processing Center at (866) 

352-7755. 

Where to File NOI Form 

See the applicable CGP for information on where to send your 

completed NOI form. 

Completing the Form 

Obtain and read a copy of the appropriate EPA Storm Water 

Construction General Permit for your area. To complete this 

form, type or print uppercase letters, in the appropriate areas 

only. Please place each character between the marks 

(abbreviate if necessary to stay within the number of 

characters allowed for each item). Use one space for breaks 

between words, but not for punctuation marks unless they are 

needed to clarify your response. If you have any questions on 

this form, refer to www.epa.gov/npdes/stormwater/cgp or 

telephone the Storm Water Notice Processing Center at (866) 

352-7755. Please submit original document with signature in 

ink . do not send a photocopied signature. 

Section I. Permit Number 

Provide the number of the permit under which you are 

applying for coverage (see Appendix B of the general permit 

for the list of eligible permit numbers). 

Section II. Operator Information 

Provide the legal name of the person, firm, public 

organization, or any other entity that operates the project 

described in this application. An operator of a project is a legal 

entity that controls at least a portion of site operations and is 

not necessarily the site manager. Provide the employer 

identification number (EIN from the Internal Revenue Service; 

IRS), also commonly referred to as your taxpayer ID. If the 

applicant does not have an EIN enter “NA” in the space 

provided. Also provide the operator’s mailing address, 

telephone number, fax number (optional) and e-mail address 

(to be notified via e-mail of NOI approval when available). 

Correspondence for the NOI will be sent to this address. 

Section III. Project/Site Information 

Enter the official or legal name and complete street address, 

including city, state, zip code, and county or similar 

government subdivision of the project or site. If the project or 

site lacks a street address, indicate the general location of the 

site (e.g., Intersection of State Highways 61 and 34). 

Complete site information must be provided for permit 

coverage to be granted. 

The applicant must also provide the latitude and longitude of 

the facility either in degrees, minutes, seconds; degrees, 

minutes, decimal; or decimal format. The latitude and longitude 

of your facility can be determined in several different ways, 

including through the use of global positioning system (GPS) 

receivers, U.S. Geological Survey (U.S.G.S.) topographic or 

quadrangle maps, and EPA’s web-based siting tools, among 

others. Refer to www.epa.gov/npdes/stormwater/cgp for further 

guidance on the use of these methodologies. For consistency, 

EPA requests that measurements be taken from the 

approximate center of the construction site. Applicants must 

specify which method they used to determine latitude and 

longitude. If a U.S.G.S. topographic map is used, applicants are 

required to specify the scale of the map used. 

Indicate whether the project is in Indian country, and if so, 

provide the name of the Reservation. If the project is in Indian 

Country Lands that are not part of a Reservation, indicate “not 

applicable” in the space provided. 

Enter the estimated construction start and completion dates 

using four digits for the year (i.e., 05/27/1998). Enter the 

estimated area to be disturbed including but not limited to: 

grubbing, excavation, grading, and utilities and infrastructure 

installation. Indicate to the nearest quarter acre. Note: 1 acre 

= 43,560 sq. ft. 

Section IV. SWPPP Information 

Indicate whether or not the SWPPP was prepared in advance 

of filing the NOI form. Check the appropriate box for the 

location where the SWPPP may be viewed. Provide the 

name, fax number (optional), and e-mail address of the 

contact person if different than that listed in Section II of the 

NOI form. 

Section V. Discharge Information 

Enter the name(s) of receiving waterbodies to which the 

project’s storm water will discharge. These should be the first 

bodies of water that the discharge will reach. (Note: If you 

discharge to more than one waterbody, please indicate all 

such waters in the space provided and attach a separate 

sheet if necessary.) For example, if the discharge leaves your 

EPA FORM 3510-9 (Rev. 11/2008) Page 3 of 4
Instructions for Completing EPA Form 3510-9 

Notice of Intent (NOI) for Storm Water Discharges Associated with 

Construction Activity Under an NPDES General Permit 

 NPDES Form Date This Form Replaces Form 3510-9 (8/98) Form Approved OMB Nos. 2040-0188 and 2040-0211 

site and travels through a roadside swale or a storm sewer 

and then enters a stream that flows to a river, the stream 

would be the receiving waterbody. Waters of the U.S. include 

lakes, streams, creeks, rivers, wetlands, impoundments, 

estuaries, bays, oceans, and other surface bodies of water 

within the confines of the U.S. and U.S. coastal waters. 

Waters of the U.S. do not include man-made structures 

created solely for the purpose of wastewater treatment. U.S. 

Geological Survey topographical maps may be used to make 

this determination. If the map does not provide a name, use a 

format such as “unnamed tributary to Cross Creek”. If you 

discharge into a municipal separate storm sewer system 

(MS4), you must identify the waterbody into which that portion 

of the storm sewer discharges. That information should be 

readily available from the operator of the MS4. 

Indicate whether your storm water discharges from 

construction activities will be consistent with the assumptions 

and requirements of applicable EPA approved or established 

TMDL(s). To answer this question, refer to 

www.epa.gov/npdes/stormwater/cgp for state- and regionalspecific TMDL information related to the construction general 

permit. You may also have to contact your EPA regional office 

or state agency. If there are no applicable TMDLs or no 

related requirements, please check the “yes” box in the NOI 

form. 

Section VI. Endangered Species Information 

Indicate for which criterion (i.e., A, B, C, D, E, or F) of the 

permit the applicant is eligible with regard to protection of 

federally listed endangered and threatened species, and 

designated critical habitat. See Part 1.3.C.6 and Appendix C 

of the permit. If you select criterion F, provide the permit 

tracking number of the operator under which you are certifying 

eligibility. The permit tracking number is the number assigned 

to the operator by the Storm Water Notice Processing Center 

after EPA acceptance of a complete NOI. 

Section VII. Certification Information 

All applications, including NOIs, must be signed as follows: 

For a corporation: By a responsible corporate officer. For the 

purpose of this Section, a responsible corporate officer 

means: 

(i) a president, secretary, treasurer, or vice-president of the 

corporation in charge of a principal business function, or any 

other person who performs similar policy- or decision-making 

functions for the corporation, or (ii) the manager of one or 

more manufacturing, production, or operating facilities, 

provided, the manager is authorized to make management 

decisions which govern the operation of the regulated facility 

including having the explicit or implicit duty of making major 

capital investment recommendations, and initiating and 

directing other comprehensive measures to assure long-term 

environmental compliance with environmental laws and 

regulations; the manager can ensure that the necessary 

systems are established or actions taken to gather complete 

and accurate information for permit application requirements; 

and where authority to sign documents has been assigned or 

delegated to the manager in accordance with corporate 

procedures. 

For a partnership or sole proprietorship: By a general partner 

or the proprietor, respectively; or 

For a municipality, state, federal, or other public agency: By 

either a principal executive officer or ranking elected official. 

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

federal agency includes (i) the chief executive officer of the 

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

for the overall operations of a principal geographic unit of the 

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

Include the name, title, and email address of the person 

signing the form and the date of signing. An unsigned or 

undated NOI form will not be considered eligible for permit 

coverage. If the NOI was prepared by someone other than the 

certifier (for example, if the NOI was prepared by the facility 

SWPPP contact or a consultant for the certifier’s signature), 

include the name, organization, phone number and email 

address of the NOI preparer. 

Paperwork Reduction Act Notice 

Public reporting burden for this application is estimated to 

average 3.7 hours. This estimate includes time for reviewing 

instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing 

the collection of information. An agency may not conduct or 

sponsor, and a person is not required to respond to, a 

collection of information unless it displays a currently valid 

OMB control number. Send comments regarding the burden 

estimate, any other aspect of the collection of information, or 

suggestions for improving this form, including any suggestions 

which may increase or reduce this burden to: Chief, 

Information Policy Branch 2136, U.S. Environmental 

Protection, Agency, 1200 Pennsylvania Avenue, NW, 

Washington, D.C. 20460. Include the OMB control number on 

any correspondence. Do not send the completed form to this 

address. 

Visit this website for mailing instructions: 

www.epa.gov/npdes/stormwater/mail

Visit this website for instructions on how to submit 

electronically: 

www.epa.gov/npdes/stormwater/enoi

EPA FORM 3510-9 (Rev. 11/2008) Page 4 of 4
EPA Form 3510-11 (09-08) Page 1 of 4 

NPDES 

FORM 

3510-11 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, DC 20460 

NO EXPOSURE CERTIFICATION FOR EXCLUSION FROM NPDES STORMWATER 

PERMITTING

Form Approved 

OMB No. 2040-0211

Submission of this No Exposure Certification constitutes notice that the entity identified in Section A does not require permit authorization for its 

stormwater discharges associated with industrial activity in the State identified in Section B under EPA’s Stormwater Multi Sector General Permit 

due to the existence of a condition of no exposure. 

A condition of no exposure exists at an industrial facility when all industrial materials and activities are protected by a storm resistant shelter to 

prevent exposure to rain, snow, snowmelt, and/or runoff. Industrial materials or activities include, but are not limited to, material handling equipment 

or activities, industrial machinery, raw materials, intermediate products, by-products, final products, or waste products. Material handling activities 

include the storage, loading and unloading, transportation, or conveyance of any raw material, intermediate product, final product or waste product. 

A storm resistant shelter is not required for the following industrial materials and activities: 

– drums, barrels, tanks, and similar containers that are tightly sealed, provided those containers are not deteriorated and do not leak. “Sealed” 

means banded or otherwise secured and without operational taps or valves; 

– adequately maintained vehicles used in material handling; and 

– final products, other than products that would be mobilized in stormwater discharges (e.g., rock salt). 

A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In addition, the exclusion from NPDES 

permitting is available on a facility-wide basis only, not for individual outfalls. If any industrial activities or materials are or will be exposed to 

precipitation, the facility is not eligible for the no exposure exclusion. 

By signing and submitting this No Exposure Certification form, the entity in Section A is certifying that a condition of no exposure exists at its facility 

or site, and is obligated to comply with the terms and conditions of 40 CFR 122.26(g). 

ALL INFORMATION MUST BE PROVIDED ON THIS FORM. 

Detailed instructions for completing this form and obtaining the no exposure exclusion are provided on pages 3 and 4. 

A. Facility Operator Information 

1. 

Name: 2. Phone: - - 

3. Email: 

4. Mailing Address: a. Street 

b. City: c. State d. Zip Code: – 

B. Facility/Site Location Information 

1. Facility Name: 

2. a. Street Address: 

b. City: c. County: 

d. State: e. Zip Code: – 

3. Is the facility located on Indian Lands? YES NO 

4. Is this a Federal facility? YES NO 

5. a. Latitude: ° ' " b. Longitude: ° ' "

6. a. Was the facility or site previously covered under an NPDES stormwater permit? YES NO 

b. If yes, enter NPDES permit number or tracking number: 

7. SIC/Activity Codes: Primary: Secondary 

(if applicable): 

8. Total size of site associated with industrial activity: acres 

9. a. Have you paved or roofed over a formerly exposed, pervious area in order to qualify for the no exposure exclusion? YES NO 

b. If yes, please indicate approximately how much area was paved or roofed over. Completing this question does not disqualify you for the no 

exposure exclusion. However, your permitting authority may use this information in considering whether stormwater discharges from your site 

are likely to have an adverse impact on water quality, in which case you could be required to obtain permit coverage. 

 Less than one acre One to five acres More than five acres 
EPA Form 3510-11 (09-08) Page 2 of 4 

C. Exposure Checklist 

 Are any of the following materials or activities exposed to precipitation, now or in the foreseeable future? 

 (Please check either “Yes” or “No” in the appropriate box.) If you answer “Yes” to any of these questions 

 (1) through (11), you are not eligible for the no exposure exclusion. Yes No 

1. Using, storing or cleaning industrial machinery or equipment, and areas where residuals from using, storing or cleaning 

industrial machinery or equipment remain and are exposed to stormwater 

2. Materials or residuals on the ground or in stormwater inlets from spills/leaks 

3. Materials or products from past industrial activity 

4. Material handling equipment (except adequately maintained vehicles) 

5. Materials or products during loading/unloading or transporting activities 

6. Materials or products stored outdoors (except final products intended for outside use [e.g., new cars] where 

exposure to stormwater does not result in the discharge of pollutants) 

7. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, and similar containers 

8. Materials or products handled/stored on roads or railways owned or maintained by the discharger 

9. Waste material (except waste in covered, non leaking containers [e.g., dumpsters]) 

10. Application or disposal of process wastewater (unless otherwise permitted) 

11. Particulate matter or visible deposits of residuals from roof stacks and/or vents not otherwise regulated 

(i.e., under an air quality control permit) and evident in the stormwater outflow 

D. Certification Statement 

I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of “no exposure” and obtaining 

an exclusion from NPDES stormwater permitting. 

I certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities or materials from the 

industrial facility or site identified in this document (except as allowed under 40 CFR 122.26(g)(2)). 

I understand that I am obligated to submit a no exposure certification form once every five years to the NPDES permitting authority and, if 

requested, to the operator of the local municipal separate storm sewer system (MS4) into which the facility discharges (where applicable). I 

understand that I must allow the NPDES permitting authority, or MS4 operator where the discharge is into the local MS4, to perform inspections 

to confirm the condition of no exposure and to make such inspection reports publicly available upon request. I understand that I must obtain 

coverage under an NPDES permit prior to any point source discharge of stormwater from the facility. 

Additionally, I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance 

with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the 

person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to 

the best of my knowledge and belief true, accurate and complete. I am aware that there are significant penalties for submitting false information, 

including the possibility of fine and imprisonment for knowing violations. 

Print Name: 

Print Title: 

Signature: 

Date: / / 

Mo Day Year 

Email: 
EPA Form 3510-11 (09-08) Page 3 of 4 

Instructions for the NO EXPOSURE CERTIFICATION for Exclusion from NPDES Stormwater Permitting

Who May File a No Exposure Certification 

Federal law at 40 CFR Part 122.26 prohibits point source 

discharges of stormwater associated with industrial activity to waters 

of the U.S. without a National Pollutant Discharge Elimination 

System (NPDES) permit. However, NPDES permit coverage is not 

required for discharges of stormwater associated with industrial 

activities identified at 40CFR 122.26(b)(14)(i)-(ix) and (xi) if the 

discharger can certify that a condition of “no exposure” exists at the 

industrial facility or site. 

Stormwater discharges from construction activities identified in 

40 CFR 122.26(b)(14)(x) and (b)(15) are not eligible for the no 

exposure exclusion. 

Obtaining and Maintaining the No Exposure Exclusion 

This form is used to certify that a condition of no exposure exists at 

the industrial facility or site described herein. This certification is only 

applicable in jurisdictions where EPA is the NPDES permitting 

authority and must be re-submitted at least once every five years. 

The industrial facility operator must maintain a condition of no 

exposure at its facility or site in order for the no exposure exclusion 

to remain applicable. If conditions change resulting in the exposure 

of materials and activities to stormwater, the facility operator must 

obtain coverage under an NPDES stormwater permit immediately. 

Where to File the No Exposure Certification Form 

No Exposure Forms sent regular mail: Forms sent overnight/express:

SW No Exposure Certification (4203M) 

USEPA 

1200 Pennsylvania Avenue, NW 

Washington, D.C. 20460 

SW No Exposure Certification

US EPA East Building, Rm. 7420

1201 Constitution Avenue, NW

Washington, D.C. 20004

(202) 564-9545

Completing the Form 

You must type or print, using uppercase letters, in appropriate areas 

only. Enter only one character per space (i.e., between the marks). 

Abbreviate if necessary to stay within the number of characters 

allowed for each item. Use one space for breaks between words. 

One form must be completed for each facility or site for which you 

are seeking to certify a condition of no exposure. Additional 

guidance on completing this form can be accessed at EPA’s 

website: www.epa.gov/npdes/stormwater. Please make sure you 

have addressed all applicable questions and have made a 

photocopy for your records before sending the completed form to 

the above address. 

Section A. Facility Operator Information 

1. Provide the legal name of the person, firm, public organization, or 

any other entity that operates the facility or site described in this 

certification. The name of the operator may or may not be the 

same as the name of the facility. The operator is the legal entity 

that controls the facility’s operation, rather than the plant or site 

manager. 

2. Provide the telephone number of the facility operator. 

3. Provide the email address of the facility operator. 

4. Provide the mailing address of the operator (P.O. Box numbers 

may be used). Include the city, state, and zip code. All 

correspondence will be sent to this address. 

Section B. Facility/Site Location Information 

1. Enter the official or legal name of the facility or site. 

2. Enter the complete street address (if no street address exists, 

provide a geographic description [e.g., Intersection of Routes 9 

and 55]), city, county, state, and zip code. Do not use a P.O. 

Box number. 

3. Indicate whether the facility is located on Indian Lands. 

4. Indicate whether the industrial facility is operated by a 

department or agency of the Federal Government (see also 

Section 313 of the Clean Water Act). 

5. Enter the latitude and longitude of the approximate center of 

the facility or site in degrees/minutes/seconds. Latitude and 

longitude can be obtained from United States Geological 

Survey (USGS) quadrangle or topographic maps, by calling 

1-(888) ASK-USGS, or by accessing the Census Bureau at: 

www.census.gov/cgi-bin/gazetteer

Latitude and longitude for a facility in decimal form must be 

converted to degrees (°), minutes ('), and seconds (") for proper 

entry on the certification form. To convert decimal latitude or 

longitude to degrees/minutes/seconds, follow the steps in the 

following example. 

Example: Convert decimal latitude 45.1234567 to degrees (°), 

minutes ('), and seconds ("). 

a) The numbers to the left of the decimal point are the degrees: 

45°. 

b) To obtain minutes, multiply the first four numbers to the right 

of the decimal point by 0.006: 1234 x 0.006 = 7.404. 

c) The numbers to the left of the decimal point in the result 

obtained in (b) are the minutes: 7'. 

d) To obtain seconds, multiply the remaining three numbers to 

the right of the decimal from the result obtained in (b) by 

0.06: 404 x 0.06 = 24.24. Since the numbers to the right of 

the decimal point are not used, the result is 24". 

e) The conversion for 45.1234567 = 45° 7' 24". 

6. Indicate whether the facility was previously covered under an 

NPDES stormwater permit. If so, include the permit number or 

permit tracking number. 

7. Enter the 4-digit SIC code which identifies the facility’s primary 

activity and second 4-digit SIC code identifying the facility’s 

secondary activity, if applicable. SIC codes can be obtained 

from the Standard Industrial Classification Manual, 1987. 

8. Enter the total size of the site associated with industrial activity 

in acres. Acreage may be determined by dividing square 

footage by 43,560, as demonstrated in the following example. 

 Example: Convert 54,450 ft2

 to acres 

Divide 54,450 ft2

 by 43,450 square feet per acre: 

54, 450 ft2 ) 43,560 ft2

/acre = 1.25 acres. 

9. Check “Yes” or “No” as appropriate to indicate whether you have 

paved or roofed over a formerly exposed, pervious area (i.e., 

lawn, meadow, dirt or gravel road/parking lot) in order to qualify 

for no exposure. If yes, also indicate approximately how much 

area was paved or roofed over and is now impervious area. 
EPA Form 3510-11 (09-08) Page 4 of 4 

Instructions for the NO EXPOSURE CERTIFICATION for Exclusion from NPDES Stormwater Permitting

Section C. Exposure Checklist 

Check “Yes” or “No” as appropriate to describe the exposure 

condition at your facility. If you answer “Yes” to ANY of the 

questions (1) through (11) in this section, a potential for exposure 

exists at your site and you cannot certify to a condition of no 

exposure. You must obtain (or already have) coverage under an 

NPDES stormwater permit. After obtaining permit coverage, you 

can institute modifications to eliminate the potential for a discharge 

of stormwater exposed to industrial activity, and then certify to a 

condition of no exposure. 

Section D. Certification Statement 

Federal statutes provide for severe penalties for submitting false 

information on this application form. Federal regulations require 

this application to be signed as follows: 

 For a corporation: by a responsible corporate officer, which 

means: 

(i) president, secretary, treasurer, or vice-president of the 

corporation in charge of a principal business function, 

or any other person who performs similar policy or 

decision making functions for the corporation, or 

(ii) the manager of one or more manufacturing, production, 

or operating facilities, provided the manager is 

authorized to make management decisions which 

govern the operation of the regulated facility including 

having the explicit or implicit duty of making major 

capital investment recommendations, and initiating and 

directing other comprehensive measures to assure long 

term environmental compliance with environmental laws 

and regulations; the manager can ensure that the 

necessary systems are established or actions taken to 

gather complete and accurate information for permit 

application requirements; and where authority to sign 

documents has been assigned or delegated to the 

manager in accordance with corporate procedures; 

 For a partnership or sole proprietorship: by a general partner 

or the proprietor, or 

 For a municipal, State, Federal, or other public facility: by 

either a principal executive or ranking elected official. 

Paperwork Reduction Act Notice 

Public reporting burden for this certification is estimated to average 

1.0 hour per certification, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the 

data needed, and completing and reviewing the collection of 

information. Burden means the total time, effort, or financial 

resources expended by persons to generate, maintain, retain, or 

disclose to provide information to or for a Federal agency. This 

includes the time needed to review instructions; develop, acquire, 

install, and utilize technology and systems for the purposes of 

collecting, validating, and verifying information, processing and 

maintaining information, and disclosing and providing information; 

adjust the existing ways to comply with any previously applicable 

instructions and requirements; train personnel to be able to 

respond to a collection of information; search data sources; 

complete and review the collection of information; and transmit or 

otherwise disclose the information. An agency may not conduct or 

sponsor, and a person is not required to respond to, a collection of 

information unless it displays a currently valid OMB control number. 

Send comments regarding the burden estimate, any other aspect 

of the collection of information, or suggestions for improving this 

form, including any suggestions which may increase or reduce this 

burden to: Director, OPPE Regulatory Information Division (2137), 

USEPA, 401 M Street, SW, Washington, D.C. 20460. Include the 

OMB control number of this form on any correspondence. Do not 

send the completed No Exposure Certification form to this address. 
EPA Form 3510-13 (Rev. 12/08) Page 1 of 2 

This Form Replaces Form 3517-7 (8-98) 

Refer to the Following Page for Instructions

Form Approved OMB Nos. 2040-0086 and 2040-0211 

NPDES 

FORM 

United States Environmental Protection Agency 

Washington, DC 20460 

Notice of Termination (NOT) of Coverage Under an NPDES General Permit for 

Stormwater Discharges Associated with Construction Activity 

Submission of this Notice of Termination constitutes notice that the party identified in Section II of this form is no longer authorized to 

discharge stormwater associated with construction activity under the NPDES program from the site identified in Section III of this form. All 

necessary information must be included on this form. Refer to the instructions at the end of this form. 

I. Permit Information 

NPDES Stormwater General Permit Tracking Number: 

Reason for Termination (Check only one): 

 Final stabilization has been achieved on all portions of the site for which you are responsible. 

 Another operator has assumed control, according to Appendix G, Section 11.C of the CGP, over all areas of the site that have not been 

finally stabilized. 

 Coverage under an alternative NPDES permit has been obtained. 

 For residential construction only, temporary stabilization has been completed and the residence has been transferred to the homeowner. 

II. Operator Information 

Name: 

IRS Employer Identification Number (EIN): – 

Mailing Address: 

Street: 

City: State: Zip Code: - 

Phone: - - Fax (optional): - - 

E-mail: 

III. Project/Site Information 

Project/Site Name: 

Project Street/Location: 

City: State: Zip Code: - 

County or similar government subdivision: 

IV. Certification Information 

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a 

system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the 

person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, 

to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false 

information, including the possibility of fine and imprisonment for knowing violations. 

Print Name: ______________________________________________________________________________________________________ 

Print Title: ________________________________________________________________________________________________________ 

Email: __________________________________________________________________________________________________________ 

Signature: _______________________________________________________________________________________________________ 

Date: ___________________________________________________________________________________________________________ 
EPA Form 3510-13 (Rev. 12/08) Page 2 of 2 

Instructions for Completing EPA Form 3510-13 

Notice of Termination (NOT) of Coverage Under an NPDES General Permit for 

Stormwater Discharges Associated with Construction Activity 

 NPDES Form This Form Replaces Form 3517-7 (8-98) Form Approved OMB Nos. 2040-0086 and 2040-0211 

Who May File an NOT Form 

Permittees who are presently covered under the EPA-issued National 

Pollutant Discharge Elimination System (NPDES) General Permit for 

Stormwater Discharges Associated with Construction Activity may 

submit an NOT form when final stabilization has been achieved on all 

portions of the site for which you are responsible; another operator has 

assumed control in accordance with Appendix G, Section 11.C of the 

General Permit over all areas of the site that have not been finally 

stabilized; coverage under an alternative NPDES permit has been 

obtained; or for residential construction only, temporary stabilization 

has been completed and the residence has been transferred to the 

homeowner. 

“Final stabilization” means that all soil disturbing activities at the site 

have been completed and that a uniform perennial vegetative cover 

with a density of at least 70% of the native background vegetative 

cover for the area has been established on all unpaved areas and 

areas not covered by permanent structures, or equivalent permanent 

stabilization measures (such as the use of riprap, gabions, or 

geotextiles) have been employed. See “final stabilization” definition in 

Appendix A of the Construction General Permit for further guidance 

where background native vegetation covers less than 100 percent of 

the ground, in arid or semi-arid areas, for individual lots in residential 

construction, and for construction projects on land used for agricultural 

purposes. 

Completing the Form 

Type or print, using uppercase letters, in the appropriate areas only. 

Please place each character between the marks. Abbreviate if 

necessary to stay within the number of characters allowed for each 

item. Use only one space for breaks between words, but not for 

punctuation marks unless they are needed to clarify your response. If 

you have any questions about this form, refer to 

www.epa.gov/npdes/stormwater/cgp or telephone the Stormwater 

Notice Processing Center at (866) 352-7755. Please submit original 

document with signature in ink - do not send a photocopied signature. 

Section I. Permit Number 

Enter the existing NPDES Stormwater General Permit Tracking 

Number assigned to the project by EPA’s Stormwater Notice 

Processing Center. If you do not know the permit tracking number, 

refer to www.epa.gov/npdes/stormwater/cgp or contact the Stormwater 

Notice Processing Center at (866) 352-7755. 

Indicate your reason for submitting this Notice of Termination by 

checking the appropriate box. Check only one: 

Final stabilization has been achieved on all portions of the site for 

which you are responsible. 

Another operator has assumed control according to Appendix G, 

Section 11.C over all areas of the site that have not been finally 

stabilized. 

Coverage under an alternative NPDES permit has been obtained. 

For residential construction only, if temporary stabilization has 

been completed and the residence has been transferred to the 

homeowner. 

Section II. Operator Information 

Provide the legal name of the person, firm, public organization, or any 

other entity that operates the project described in this application and 

is covered by the permit tracking number identified in Section I. The 

operator of the project is the legal entity that controls the site operation, 

rather than the site manager. Provide the employer identification 

number (EIN from the Internal Revenue Service; IRS). If the applicant 

does not have an EIN enter “NA” in the space provided. Enter the 

complete mailing address, telephone number, and email address of 

the operator. Optional: enter the fax number of the operator. 

Section III. Project/Site Information 

Enter the official or legal name and complete street address, 

including city, state, zip code, and county or similar government 

subdivision of the project or site. If the project or site lacks a street 

address, indicate the general location of the site (e.g., Intersection of 

State Highways 61 and 34). Complete site information must be 

provided for termination of permit coverage to be valid. 

Section IV. Certification Information 

All applications, including NOIs, must be signed as follows: 

For a corporation: By a responsible corporate officer. For the 

purpose of this Part, a responsible corporate officer means: (i) a 

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

charge of a principal business function, or any other person who 

performs similar policy-or decision-making functions for the 

corporation, or (ii) the manager of one or more manufacturing, 

production, or operating facilities, provided, the manager is 

authorized to make management decisions which govern the 

operation of the regulated facility including having the explicit or 

implicit duty of making major capital investment recommendations, 

and initiating and directing other comprehensive measures to assure 

long-term environmental compliance with environmental laws and 

regulations; the manager can ensure that the necessary systems are 

established or actions taken to gather complete and accurate 

information for permit application requirements; and where authority 

to sign documents has been assigned or delegated to the manager 

in accordance with corporate procedures. 

For a partnership or sole proprietorship: By a general partner or the 

proprietor, respectively; or 

For a municipality, state, federal, or other public agency: By either a 

principal executive officer or ranking elected official. For purposes of 

this Part, a principal executive officer of a federal agency includes (i) 

the chief executive officer of the agency, or (ii) a senior executive 

officer having responsibility for the overall operations of a principal 

geographic unit of the agency (e.g., Regional Administrator of EPA). 

Include the name, title, and email address of the person signing the 

form and the date of signing. An unsigned or undated NOT form will 

not be considered valid termination of permit coverage. 

Paperwork Reduction Act Notice 

Public reporting burden for this application is estimated to average 

0.5 hours per notice, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the data 

needed, and completing and reviewing the collection of information. 

An agency may not conduct or sponsor, and a person is not required 

to respond to, a collection of information unless it displays a currently 

valid OMB control number. Send comments regarding the burden 

estimate, any other aspect of the collection of information, or 

suggestions for improving this form including any suggestions which 

may increase or reduce this burden to: Chief, Information Policy 

Branch, 2136, U.S. Environmental Protection Agency, 1200 

Pennsylvania Avenue, NW, Washington, DC 20460. Include the 

OMB number on any correspondence. Do not send the completed 

form to this address. 

Visit this website for mailing instruction: 

www.epa.gov/npdes/stormwater/mail

Visit this website for instructions on how to submit electronically: 

www.epa.gov/npdes/stormwater/enoi
APPENDIX J
 
 

NPDES COMPLIANCE INSPECTION REPORT
 
 

FORM 3560-3

 Revised April 2006
 
 
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United States Environmental Protection Agency
 


Washington, D.C. 20460
 


Water Compliance Inspection Report 

Section A: National Data System Coding (i.e., PCS)
 

Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
 

1 2 5 3 11 12 17 18 19 20

Remarks 

21 66

Inspection Work Days Facility Self-Monitoring Evaluation Rating BI QA -----------------------------Reserved--------------------------­

67 ! 69 70 71 72 73 74 75 80

Section B: Facility Data 

Name and Location of Facility Inspected (For industrial users discharging to POTW, also Entry Time/Date Permit Effective Date 

include POTW name and NPDES permit number) 

Exit Time/Date Permit Expiration Date 

Name(s) of On-Site Representative(s)/Title(s)/Phone and Fax Number(s) Other Facility Data (e.g., SIC NAICS, and other descriptive information) 

Name, Address of Responsible Official/Title/Phone and Fax Number Contacted

G Yes G No

Section C: Areas Evaluated During Inspection (Check only those areas evaluated) 

Permit Self-Monitoring Program Pretreatment MS4 

Records/Reports Compliance Schedules Pollution Prevention

Facility Site Review Laboratory Storm Water 

Effluent/Receiving Waters Operations & Maintenance Combined Sewer Overflow 

Flow Measurement Sludge Handling/Disposal Sanitary Sewer Overflow 

Section D: Summary of Findings/Comments 

(Attach additional sheets of narrative and checklists, including Single Event Violation codes, as necessary) 

SEV Codes SEV Description 

99999 _________________________________________________ 

99999 _________________________________________________ 

99999 _________________________________________________ 

99999 _________________________________________________ 

Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Date 

Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date 

EPA Form 3560-3 (Rev 4-06) Previous editions are obsolete. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS 

Section A: National Data System Coding (i.e., PCS) 

Column 1: Transaction Code: Use N, C, or D for New, Change, or Delete. All inspections will be new unless there is an error in the data entered. 

Columns 3-11: NPDES Permit No. Enter the facility's NPDES permit number - third character in permit number indicates permit type for U=unpermitted, 

G=general permit, etc.. (Use the Remarks columns to record the State permit number, if necessary.) 

Columns 12-17: Inspection Date. Insert the date entry was made into the facility. Use the year/month/day format (e.g., 04/10/01 = October 01, 2004). 

Column 18: Inspection Type*. Use one of the codes listed below to describe the type of inspection: 

A Performance Audit U IU Inspection with Pretreatment Audit ! Pretreatment Compliance (Oversight) 

B 

C 

Compliance Biomonitoring 

Compliance Evaluation (non-sampling) 

X 

Z 

Toxics Inspection 

Sludge - Biosolids @ Follow-up (enforcement) 

D Diagnostic # Combined Sewer Overflow-Sampling { Storm Water-Construction-Sampling 

F 

G 

Pretreatment (Follow-up) 

Pretreatment (Audit) 

$ 

+ 

Combined Sewer Overflow-Non-Sampling 

Sanitary Sewer Overflow-Sampling } Storm Water-Construction-Non-Sampling 

I 

J 

M 

N 

O 

P 

R 

Industrial User (IU) Inspection 

Complaints 

Multimedia 

Spill 

Compliance Evaluation (Oversight) 

Pretreatment Compliance Inspection 

Reconnaissance 

& 

\ 

= 

2 

3 

4 

5 

Sanitary Sewer Overflow-Non-Sampling 

CAFO-Sampling 

CAFO-Non-Sampling 

IU Sampling Inspection 

IU Non-Sampling Inspection 

IU Toxics Inspection 

IU Sampling Inspection with Pretreatment 

: 

~ 

< 

-

> 

Storm Water-Non-Construction-Sampling 

Storm Water-Non-ConstructionNon-Sampling Storm Water-MS4-Sampling 

Storm Water-MS4-Non-Sampling 

Storm Water-MS4-Audit 

S Compliance Sampling 6 IU Non-Sampling Inspection with Pretreatment 

7 IU Toxics with Pretreatment 

Column 19: Inspector Code. Use one of the codes listed below to describe the lead agency in the inspection. 

A — State (Contractor) O— Other Inspectors, Federal/EPA (Specify in Remarks columns) B ---- EPA (Contractor) P— Other Inspectors, State (Specify in Remarks columns) E — Corps of Engineers R — EPA Regional Inspector J — Joint EPA/State Inspectors—EPA Lead S — State Inspector L ---- Local Health Department (State) T — Joint State/EPA Inspectors—State lead N — NEIC Inspectors 

Column 20: Facility Type. Use one of the codes below to describe the facility. 

1 — Municipal. Publicly Owned Treatment Works (POTWs) with 1987 Standard Industrial Code (SIC) 4952.
 


2 — Industrial. Other than municipal, agricultural, and Federal facilities.
 


3 — Agricultural. Facilities classified with 1987 SIC 0111 to 0971.
 


4 — Federal. Facilities identified as Federal by the EPA Regional Office.
 


5 — Oil & Gas. Facilities classified with 1987 SIC 1311 to 1389.
 


Columns 21-66: Remarks. These columns are reserved for remarks at the discretion of the Region.
 


Columns 67-69: Inspection Work Days. Estimate the total work effort (to the nearest 0.1 work day), up to 99.9 days, that were used to complete the
 


inspection and submit a QA reviewed report of findings. This estimate includes the accumulative effort of all participating inspectors; any effort for laboratory
 


analyses, testing, and remote sensing; and the billed payroll time for travel and pre and post inspection preparation. This estimate does not require detailed
 


documentation.
 


Column 70: Facility Evaluation Rating. Use information gathered during the inspection (regardless of inspection type) to evaluate the quality of the facility
 


self-monitoring program. Grade the program using a scale of 1 to 5 with a score of 5 being used for very reliable self-monitoring programs, 3 being
 


satisfactory, and 1 being used for very unreliable programs.
 


Column 71: Biomonitoring Information. Enter D for static testing. Enter F for flow through testing. Enter N for no biomonitoring.
 


Column 72: Quality Assurance Data Inspection. Enter Q if the inspection was conducted as followup on quality assurance sample results. Enter N
 


otherwise.
 


Columns 73-80: These columns are reserved for regionally defined information.
 


Section B: Facility Data 

This section is self-explanatory except for "Other Facility Data," which may include new information not in the permit or PCS (e.g., new outfalls, names of 

receiving waters, new ownership, other updates to the record, SIC/NAICS Codes, Latitude/Longitude). 

Section C: Areas Evaluated During Inspection 

Check only those areas evaluated by marking the appropriate box. Use Section D and additional sheets as necessary. Support the findings, as necessary, 

in a brief narrative report. Use the headings given on the report form (e.g., Permit, Records/Reports) when discussing the areas evaluated during the 

inspection. 

Section D: Summary of Findings/Comments 

Briefly summarize the inspection findings. This summary should abstract the pertinent inspection findings, not replace the narrative report. Reference a 

list of attachments, such as completed checklists taken from the NPDES Compliance Inspection Manuals and pretreatment guidance documents, including 

effluent data when sampling has been done. Use extra sheets as necessary. 

*Footnote: In addition to the inspection types listed above under column 18, a state may continue to use the following wet weather and CAFO inspection 

types until the state is brought into ICIS-NPDES: K: CAFO, V: SSO, Y: CSO, W: Storm Water 9: MS4. States may also use the new wet weather, CAFO 

and MS4 inspections types shown in column 18 of this form. The EPA regions are required to use the new wet weather, CAFO, and MS4 inspection types 

for inspections with an inspection date (DTIN) on or after July 1, 2005. 
 

 

Attachment 3 ­

Single Event Violation Table
 
             

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single Event Violation Table ­ Codes and Descriptions*
 

CODE DESCRIPTION CODE DESCRIPTION 

Effluent Violations CSO 

A0018 Approved Bypass A0C18 Approved Bypass 

A0013 Failed Toxicity Test A0024 Dry weather overflow 

A0023 Industrial Spill B0030 Failure to Develop Adequate LTCP 

A0017 Inspection sample above historic DMR range B0031 Failure to Implement LTCP 

A0022 Narrative Effluent Violation B0029 Failure to Implement Nine Minimum Controls (NMCs) 

A0012 Numeric effluent violation BC291 Failure to implement required NMC #1(Proper operation and maintenance) 

A0016 Reported Fish Kill BC292 Failure to implement required NMC #2 (Maximum use of the collection 

system) 

A0011 Unapproved Bypass BC293 Failure to implement required NMC #3 (Review pretreatment 

requirements) 

A0015 Unauthorized Discharge of Brine BC294 Failure to implement required NMC #4 (Maximization of flow) 

Management Practice Violations BC295 Failure to implement required NMC #5 (Elimination of dry weather flow) 

B0019 Best Management Practice Deficiencies BC296 Failure to implement required NMC #6 (Control of solids) 

B0024 Biosolids/Sewage Sludge Violation (Part 503) BC297 Failure to implement required NMC #7 (Pollution prevention programs) 

B0026 Failure to Allow Entry BC298 Failure to implement required NMC #8 (Public notification) 

B0012 Failure to Conduct Inspections BC299 Failure to implement required NMC #9 (Monitoring) 

B0027 Failure to Develop Adequate SPCC Plan B0C41 Failure to Maintain Records or Meet Record Keeping Requirements 

B0017 Failure to develop any or adequate SWPPP/SWMP C0C11 Failure to monitor 

B0011 Failure to Develop/Enforce Standards E0C16 Failure to submit required report (non-DMR) 

B0028 Failure to Implement SPCC Plan E0C13 Improper/Incorrect reporting 

B0018 Failure to Implement SWPPP/SWMP B0044 LTCP implementation schedule milestone missed 

B0041 Failure to Maintain Records A0C22 Narrative effluent violation 

B0040 Improper Chemical Handling E0C14 Noncompliance with section 308 Information Request 

B0023 Improper Land Application (non-503, non-CAFO) A0C12 Numeric effluent violation 

B0020 Improper Operation and Maintenance A0C11 Related Unapproved Bypass 

B0025 Inflow/Infiltration (I/I) A0021 Unauthorized CSO Discharge to Waters/Wet Weather 

B0021 Laboratory Not Certified A0025 Unauthorized overflow to dry land or building backup 

B0022 No Licensed/Certified Operator B0045 Violation of a milestone in a permit 

B0042 Violation of a milestone in an order B0C42 Violation of a milestone in an order 

Monitoring Violations SSO 

C0017 Analysis not Conducted A0S18 Approved Bypass 

C0011 Failure to Monitor for non-Toxicity Requirements A0020 Discharge to Waters 

C0021 Failure to Monitor for Toxicity Requirements D0S11 Discharge without a valid permit (includes satellite systems) 

C0015 Frequency of Sampling Violation B0S41 Failure to Maintain Records or Meet Record Keeping Requirements 

C0018 Improper Analysis or Lab Error C0S11 Failure to monitor 

C0014 Invalid/Unrepresentative Sample E0018 Failure to report other violation 

C0016 No Flow Measurement Device E0019 Failure to report violation that may endanger public health 122.41(l)(7) 

Permitting Violations D0S12 Failure to submit required permit application info (includes satellite 

systems) 

D0014 Application Incomplete B0S20 Improper Operation and Maintenance 

D0011 Discharge Without a Valid Permit A0S22 Narrative effluent violation 

D0012 Failure to Apply for a Permit E0S14 Noncompliance with section 308 Information Request 

D0015 Failure to Pay Fees A0S12 Numeric effluent violation 

D0016 Failure to Submit Timely Permit Renewal Application A0026 Overflow to Dry Land or Building Backup 

D0013 Unapproved Operation A0S11 Related Unapproved Bypass 

D0017 Violation Specified in Comment BS42A Violation of milestone in an administrative order 

BS42J Violation of milestone in judicial decree 

B0046 Violation of sewer moratorium or restriction 

Reporting Violations Storm Water Construction 

E0017 Failure to Notify D0R11 Discharge without a permit 

1
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E0012 Failure to Submit DMRs D0R18 Failure to apply for a notice of termination 

E0016 Failure to submit required report (non-DMR, non-pretreatment) B0R12 Failure to Conduct Inspections 

E0013 Improper/ Incorrect Reporting B0C17 Failure to develop any or adequate SWPPP/SWMP 

E0011 Late Submittal of DMRs B0C18 Failure to Implement SWPPP/SWMP 

E0014 Noncompliance with Section 308 Information Request B0R41 Failure to Maintain Records 

Pretreatment C0R11 Failure to Monitor 

C0012 Baseline Monitoring Report Violation BR19A Failure to properly install/implement BMPs 

B0P12 Failure to Conduct Inspections BR19B Failure to properly operate and maintain BMPs 

B0P11 Failure to Develop/Enforce Standards D0R12 Failure to submit required permit application information 

B0013 Failure to Enforce Against I/U E0R16 Failure to submit required report (non-DMR) 

B0015 Failure to Establish Local Limits A0R22 Narrative effluent violation 

C0013 Failure to Establish Self-Monitoring Requirements E0R14 Noncompliance with section 308 Information Request 

B0014 Failure to Issue SIU Permits A0R12 Numeric Effluent Violation 

B0016 Failure to Meet Inspection and Sampling Plan for SIUs B0R42 Violation of a milestone in an order 

E0015 Failure to submit required report (non-DMR) Storm Water MS4 

B0P40 Improper Chemical Handling D0M11 Discharge without a permit 

A0014 IU Violation of Pretreatment Standards D0M18 Failure to apply for a notice of termination 

CAFO B0M12 Failure to Conduct Inspections 

B0A19 Best Management Practice Deficiencies B0M17 Failure to develop any or adequate SWPPP/SWMP 

B0038 Direct Animal Contact with Waters of US B0M18 Failure to Implement SWPPP/SWMP 

D0A11 Discharge without a permit B0M41 Failure to Maintain Records or Meet Record Keeping 

B0A12 Failure to Conduct Inspections C0M11 Failure to Monitor 

B0032 Failure to Develop any or adequate NMP BM19A Failure to properly install/implement BMPs 

B0033 Failure to Implement NMP BM19B Failure to properly operate and maintain BMPs 

B0A41 Failure to Maintain Records or Meet Record Keeping 

Requirements D0M12 Failure to submit required permit application information 

B0043 Failure to meet order final compliance date E0M16 Failure to submit required report (non-DMR) 

C0A11 Failure to Monitor A0M22 Narrative effluent violation 

D0A12 Failure to submit required permit application information E0M14 Noncompliance with section 308 Information Request 

C0019 Failure to Test Manure A0M12 Numeric Effluent Violation 

B0A40 Improper Chemical Handling B0M42 Violation of a milestone in an order 

B0A23 Improper Land Application Storm Water Non-Construction 

B0039 Improper Manure Handling (not including land application) D0N11 Discharge without a permit 

B0037 Improper Mortality Management D0N18 Failure to apply for a notice of termination 

B0036 Improper O&M of Storage Facility B0N12 Failure to Conduct Inspections 

E0A13 Improper/Incorrect reporting B0N17 Failure to develop any or adequate SWPPP/SWMP 

B0034 Insufficient Buffers/Setbacks B0N18 Failure to Implement SWPPP/SWMP 

B0035 Insufficient Storage Capacity B0N41 Failure to Maintain Records 

A0A22 Narrative effluent violation C0N11 Failure to Monitor 

E0A16 No Annual Report Submitted BN19A Failure to properly install/implement BMPs 

C0020 No Depth Marker BN19B Failure to properly operate and maintain BMPs 

E0A14 Noncompliance with section 308 Information Request D0N12 Failure to submit required permit application information 

A0A12 Numeric effluent violation E0N16 Failure to submit required report (non-DMR) 

A0019 Production Area Runoff A0N22 Narrative effluent violation 

B0A42 Violation of a milestone in an order E0N14 Noncompliance with section 308 Information Request 

A0N12 Numeric Effluent Violation 

B0N42 Violation of a milestone in an order 

* N. B. The codes and code names listed herein may change over time. Please consult ICIS-NPDES and PCS system 

documentation for updated lists. 

2
 
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EPA Form 7500-62 (Rev. 11/08) 

See page three for instructions Form Approved OMB No. 2040-0211

NPDES 

FORM 

United States Environmental Protection Agency 

Washington, DC 20460 

Low Erosivity Waiver Certification

This form provides notice to EPA that you, the project operator identified in Section I of this form, are certifying that construction 

activity at the project site identified in Section II, will take place during a period when the rainfall erosivity factor is less than five 

[40 CFR 122.26(b)(15)(i)(A)]. By submitting a complete and accurate form, the otherwise applicable NPDES permitting 

requirements for stormwater discharges associated with construction activity, are waived. Based on your certification, a waiver is 

granted for the period beginning on the date this Low Erosivity Waiver Form is mailed to EPA (i.e., postmark date), or the project 

start date specified in Part III of this form, whichever shall occur last, and ending on the project completion date specified in 

Part III. Refer to the instructions at the end of this form for more details. 

I. Operator Information 

Company 

Name: 

IRS Employer Identification Number (EIN): – 

Mailing Address: 

Street: 

City: State: Zip Code: - 

Contact Name: 

Phone: - - Fax (optional): - - 

Email: 

II. Construction Project/Site Information 

Project/Site Name: 

Project Street/Location: 

City: State: Zip Code: - 

County or similar government subdivision: 

Latitude and Longitude (Use one of three formats given, and specify the source) 

1. Degrees, minutes, seconds (e.g., 76°, 30 ́, 45 ̋) Latitude: °  ́  ̋ N Longitude: °  ́  ̋ W

2. Degrees, minutes with 2 decimal places (e.g., 76° 30.75 ́) ° .  ́ N ° .  ́ W

3. Degrees, minutes with 4 decimal places (e.g., 76.5125°) . ° N . ° W

• Lat/Lon source? USGS topographic map EPA Web siting tool GPS Other (specify source): 

• If you used a USGS topographic map, what is the scale? 

• Horizontal Reference Datum? NAD 27 NAD 83 or WGS 84 Unknown 

• Is the project located on Indian country? Yes No If yes, enter Indian reservation name 

• Is the project a federal facility or part of a federal facility? Yes No 

• Is the project located in the State of Oklahoma and associated with oil and gas exploration, drilling, operations, and pipelines 

(includes SIC Groups 13 and 46, and SIC codes 492 and 5171)? Yes No 

• Is the project located in the State of Oklahoma and associated with agricultural production, services and silviculture 

(includes SIC Groups 01, 02, 07, 08 and 09)? Yes No 

• Is the project located in the State of Texas and associated with the exploration, development, or production of oil or gas or geothermal 

resources, including transportation or crude oil or natural gas by pipeline? Yes No 

Estimated Area to be Disturbed (to the nearest quarter acre): - 
EPA Form 7500-62 (Rev. 11/08) 

III. Rainfall Erosivity Factor Calculation Data 

Project Start Date: / / Project Completion Date: / / 

 Month Day Year Month Day Year 

Are interim non-vegetative site stabilization measures used to establish the project completion date for 

purposes of obtaining this waiver? Yes No 

Rainfall erosivity factor (R factor): 

Note: To qualify for this waiver, the construction activity must take place during a period when the R factor is less than five. 

Rainfall erosivity factor was calculated by using: Online calculator EPA Fact Sheet 3-1 USDA Handbook 703 

. 

IV. Operator Certification 

I certify under penalty of law that: (1) construction activity at the project or site specified in Part II shall disturb less than five acres 

and shall take place during a period when the rainfall erosivity factor is less than five, (2) final stabilization will be completed as 

defined in the Construction General Permit, and (3) this document and all attachments were prepared under my direction or 

supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the 

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

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

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

imprisonment for knowing violations. Further, if interim non-vegetative measures are used to establish the end of the construction 

period for the purposes of obtaining this waiver, I commit to periodically inspect and properly maintain the area until the criteria for 

final vegetative stabilization have been met. 

Print Name: 

Print Title: 

Signature: Date: / / 

Month Day Year 

Email: 
Instructions for Completing EPA Form 7500-62 (Rev. 11/08) 

Low Erosivity Waiver Certification 

 NPDES Form Form Approved OMB No. 2040-0211 

EPA Form 7500-62 (Rev. 11/08) 

Who May Qualify for a Low Erosivity Waiver 

Under the National Pollutant Discharge Elimination System 

(NPDES) Program, operators of construction projects that result 

in land disturbances equal to or greater than one acre, including 

sites that are less than one acre but are part of a larger common 

plan of development or sale where there is a cumulative 

disturbance of at least one acre, are required to obtain coverage 

under an NPDES permit for stormwater discharges associated 

with construction activity. EPA may waive the otherwise 

applicable permit requirements for stormwater discharges from 

construction activities that disturb less than five acres if the 

construction activity will take place during a period when the 

rainfall erosivity factor (R factor) is less than five. More 

information on the low erosivity waiver is available on the web in 

the Construction Rainfall Erosivity Waiver Fact Sheet at

www.epa.gov/npdes/pubs/fact3-1.pdf and can be accessed from

www.epa.gov/npdes/cgp. For questions related to completion of 

this form, you may contact EPA’s Stormwater Notice Processing 

Center toll free at 1-866-352-7755. 

Completing the Form 

Type or print, using uppercase letters, in the appropriate areas 

only. Please place each character between the marks. Abbreviate 

if necessary to stay within the number of characters allowed for 

each item. Use only one space for breaks between words, but not 

for punctuation marks unless they are needed to clarify your 

response. Please submit the original form with a signature in 

ink. EPA will not accept a photocopied signature. 

Section I. Operator Information 

Each legal entity that meets EPA’s definition of “operator” (see 

definitions in Appendix A of EPA’s NPDES Construction General 

Permit) and that meets the eligibility conditions for the low 

erosivity waiver must file this form to have the permit 

requirements waived. The operator is the legal entity that either 

(1) has operational control over construction plans and 

specifications, including the ability to make modifications to those 

plans and specifications, or (2) has day-to-day operational control 

of some or all of those activities. It is possible that there will be 

more than one operator at a site and, in such cases, each entity 

that meets the operator definition must complete a Low Erosivity 

Waiver Certification. Provide the legal name of your firm, public 

organization, or other entity that operates the project described in 

this waiver certification. Usually this will be a company or 

organization’s name but for construction activities undertaken by 

you as an individual, this should be your name. Provide the 

operator’s Internal Revenue Service (IRS) employer identification 

number (EIN), commonly referred to as the “taxpayer ID.” If you 

are completing this form as an individual (i.e., not representing a 

company or organization), enter “NA” in the space provided for 

EIN. Enter the operator’s complete mailing address and name of 

contact person, telephone number and email who can answer 

questions about the site (e.g., a project or site manager). 

Optional: to facilitate communication, provide a fax number for the 

contact person. 

To determine whether EPA is the permitting authority for the 

construction project, and thus has authority to waive the 

otherwise applicable requirements of the Construction General 

Permit, it is necessary to know whether the project is located in 

Indian country, is a federal facility or part of a federal facility; and 

to answer the other three questions on projects located in 

Oklahoma and Texas. 

Section II. Construction Project/Site Information 

Enter the official or legal name and complete street address, 

including city, state, zip code, and county or similar government 

subdivision of the project or site. If the project lacks a street 

address, indicate the general location of the site (e.g., intersection 

of State Highways 61 and 34). 

The applicant must also provide the latitude and longitude of the 

approximate center of the project/site using one of three formats 

given in the form. The latitude and longitude of your facility can be 

determined from several sources, including global positioning 

system (GPS) receivers, U.S. Geological Survey (USGS) 

topographic or quadrangle maps, and EPA's Web-based siting 

tool, among others. Information on using these methods to find 

your construction site’s latitude and longitude is available on the 

web at www.epa.gov/npdes/cgp. This web page describes EPA’s 

web-based siting tool, which combines interactive maps and 

aerial photographs to help find your construction site’s latitude 

and longitude. Specify which source you used to determine 

latitude and longitude. If a USGS topographic map is used, 

specify the scale of the map used. 

Enter the horizontal reference datum for your latitude and 

longitude. The 1927 North American Datum (NAD 27) is a set of 

ellipsoid constants that describe the earth’s shape and are used 

to calculate locations on the earth’s latitude-longitude grid. This 

1927 datum provides the mathematical basis for latitude and 

longitude coordinates on most USGS topographic maps. 

However, this datum is being phased out. Latitude and longitude 

on new or revised maps are now being calculated using the 1983 

North American Datum (NAD 83), which is based on a newer 

definition of the earth ellipsoid. The World Geodetic System 

datum (WGS 84) was developed for the Department of Defense 

(DOD), who wanted a new coordinate system for the entire earth 

not just North America. DOD was willing to sacrifice a little 

accuracy in North America to get a better world system. For our 

purposes we don’t have to be concerned about WGS 84 to NAD 

83 coordinate conversions because the differences are negligible. 

The horizontal reference datum used on USGS topographic 

maps is shown on the bottom left corner of USGS topographic 

maps; it is also available for GPS receivers; but it is not provided 

on EPA’s web-based siting tool. If you use EPA's web siting tool, 

please check the “unknown” box. NAD 83 is the most accurate 

reference datum and, as such, is preferred. 

Enter the area (estimated to the nearest quarter acre) to be 

disturbed including, but not limited to: grubbing, excavation, 

grading, and utilities and infrastructure installation. Note: 1 acre = 

43,560 sq. ft. 

Section III. Rainfall Erosivity Factor Calculation Data 

The construction period begins with the initial earth disturbance 

and ends with final site stabilization. To qualify for this waiver, the 

rainfall erosivity factor for the project must be less than five during 

the entire construction period. Specify the construction period by 

entering the project start date (date of initial earth disturbance) 

and project completion date (date of final site stabilization). For 

example, a grading contractor that is operating on-site for only 

one week during a nine month construction project, must enter 

the start date and completion date of the entire nine month 

construction period. 
Instructions for Completing EPA Form 7500-62 (Rev. 11/08) 

Low Erosivity Waiver Certification 

 NPDES Form Form Approved OMB No. 2040-0211 

EPA Form 7500-62 (Rev. 11/08) 

EPA believes, where the environmental threat is low (i.e., in arid 

and semi-arid climates), that “final stabilization” can include 

techniques that employ re-vegetation combined with other 

stabilization measures, consisting of temporary degradeable 

rolled erosion control products, also known as “erosion control 

blankets (ECBs). With proper selection, design, and installation of 

the combination re-vegetation/ECB technique in arid or semi-arid 

areas, an operator can be considered to have achieved final 

stabilization upon completion of the installation process. Note that 

if more than three years is required to establish 70 percent of the 

natural vegetative cover, this technique cannot be used or cited 

for fulfillment of the final stabilization requirement. If your waiver is 

based on use of interim non-vegetative stabilization measures, 

such as erosion control blankets, to establish the end of the 

construction period, you must indicate so on this form. In doing 

so, you must commit and certify (as a condition of waiver 

eligibility) to periodically inspect and properly maintain the area 

until the criteria for final stabilization, as defined in the 

Construction General Permit, have been met. 

The rainfall erosivity factor "R" is determined in accordance with 

the U.S. Department of Agriculture Agriculture Handbook Number 

703, Prediciting Soil Erosion by Water: A Guide to Conservation 

Planning with the Revised Universal Soil Loss Equation (RUSLE), 

Chapter 2 pages 21-64, dated January 1997. EPA's Construction 

Rainfall Erosivity Waiver Fact Sheet (EPA 833-F-00-014), 

available online at www.epa.gov/npdes/pubs/fact3-1.pdf, defines 

rainfall erosivity and provides numerical examples showing how 

to calculate your rainfall erosivity factor. You may use the fact 

sheet approach or the online rainfall erosivity factor calculator 

available at: http://ei.tamu.edu to calculate your rainfall erosivity 

factor for your project. 

If the R factor is five or greater during the project’s construction 

period, you must have or obtain coverage under an NPDES 

stormwater permit. If the project was eligible for the waiver during 

the original construction period, but the construction activity will 

extend past the project completion date specified in the Low 

Erosivity Waiver Certification, the operator must recalculate the R 

factor using the original start date and a new project completion 

date. If the recalculated R factor is still less than five, a new 

waiver certification form must be submitted before the end of the 

original construction period. If the new R factor is five or greater, 

the operator must submit a Notice of Intent to be covered by the 

Construction General Permit before the original project 

completion date. The Notice of Intent (NOI) form may be 

submitted electronically using EPA’s eNOI system at 

www.epa.gov/npdes/enoi or submitted by mailing the paper NOI 

form (EPA Form 3510-9) available on the EPA website at 

www.epa.gov/npdes/cgp. 

Section IV. Operator Certification 

All Low Erosivity Waiver Certification forms must be signed as 

follows: 

For a corporation: By a responsible corporate officer. For the 

purpose of this Section, a responsible corporate officer means: 

(i) president, secretary, treasurer, or vice president of the 

corporation in charge of a principal business function, or any 

other person who performs similar policy-or decision-making 

functions for the corporation, or (ii) the manager of one or more 

manufacturing, production, or operating facilities, provided the 

manager is authorized to make management decisions which 

govern the operation of the regulated facility including having the 

explicit or implicit duty of making major capital investment 

recommendations, and initiating and directing other 

comprehensive measures to assure long-term environmental 

compliance with environmental laws and regulations; the 

manager can ensure the necessary systems are established or 

actions taken to gather complete and accurate information for 

permit application requirements; and where authority to sign 

documents has been assigned or delegated to the manager in 

accordance with corporate procedures; 

For a partnership or sole proprietorship: By a general partner or 

the proprietor, respectively; or 

For a municipality, state, federal, or other public facility: By either 

a principal executive officer or ranking elected official. For 

purposes of this Section, a principal executive officer of a federal 

agency includes (i) the chief executive officer of the agency, or (ii) 

a senior executive officer having responsibility for the overall 

operations of a principal geographic unit of the agency (e.g., 

Regional Administrator of EPA). 

Include the name, title, and email address of the person signing 

the form and the signature date. An unsigned or undated Low 

Erosivity Waiver Certification will not be considered valid. 

Where to File This Form 

Low Erosivity Waiver Certification forms must be sent to one of 

the following two addresses. 

Regular U.S. Mail Delivery 

EPA Stormwater Notice 

Processing Center 

Mail Code 4203M 

U.S. EPA 

1200 Pennsylvania Avenue, NW 

Washington, DC 20460 

Overnight/Express Mail Delivery

EPA Stormwater Notice 

Processing Center 

Room 7420 

U.S. EPA 

1201 Constitution Avenue, NW 

Washington, DC 20004 

Please submit the original form with a signature in ink. Do not 

send a photocopied signature! 

Paperwork Reduction Act Notice 

Public reporting burden for this certification form is estimated to 

average 1.0 hours. This estimate includes time for reviewing 

instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing the 

collection of information. An agency may not conduct or sponsor, 

and a person is not required to respond to, a collection of 

information unless it displays a currently valid OMB control 

number. Send comments regarding the burden estimate, any 

other aspect of the collection of information, or suggestions for 

improving this form, including any suggestions which may 

increase or reduce this burden to: Chief, Information Strategies 

Branch (2822T), U.S. Environmental Protection, Agency, 1200 

Pennsylvania Avenue, NW, Washington, D.C. 20460. Include the 

OMB control number on any correspondence. Do not send the 

completed form to this address. 
STANDARD FORM 299 (1/2006) 

Prescribed by DOI/USDA/DOT 

P.L. 96487 and Federal Register Notice 5-22-95 APPLICATION FOR TRANSPORTATION AND 

UTILITY SYSTEMS AND FACILITIES 

ON FEDERAL LANDS 

6. If an individual, or partnership are you a citizen(s) of the United States? 

7. Project description [describe in detail): (a) Type of system or facility, (e.g., canal, pipeline, road); (b) related structures and facilities; (c) physical specifications 

(length, width, grading, etc.); (d) (d) term of years needed; (e) time of year of use or operation; (f) Volume or amount of product to be transported; (g) duration and 

Yes No 

timing of construction; and (h) temporary work areas needed for construction (Attach additional sheets, if additional space is needed,) 

NOTE: Before completing and filing the application, the applicant should completely review this package and schedule a preapplication meeting with representatives of the agency responsible for processing the application. Each agency 

may have specific and unique requirements to be met in preparing and processing the application. Many times, with 

the help of the agency representative, the application can be completed at the preapplication meeting. 

Name and address of applicant (include zip code) 

4. As applicant are you? (check one) 

a. Individual 

b. Corporation* 

c. 

d. State Government/State Agency 

e. Local Government 

f. Federal Agency 

* If checked, complete supplemental page 

2. Name, title, and address of authorized agent if different 

from Item 1 (include zip code) 

FORM APPROVED 

OMB NO. 1004-0189 

Expires: November 30, 2008

FOR AGENCY USE ONLY 

Application Number 

Date filed 

3. TELEPHONE (area code) 

Applicant 

Authorized Agent 

5. Specify what application is for: (check one) 

a. New authorization 

b. Renewing existing authorization No. 

c. Amend existing authorization No. 

d. Assign existing authorization No. 

e. Existing use for which no authorization has been received* 

f. Other* 

* provide details under Item 7 

8. Attach a map covering area and show location of project proposal 

9. State or local government approval: Attached Applied for Not required 

Nonreturnable application fee. Attached Not required 

Does project cross international boundary or affect international waterways? Yes 

Give statement of your technical and financial capability to construct, operate, maintain, and terminate system for which authorization is being requested. 

No (If "yes," indicate on map)

(Continued on page 2 ) This form is authorized for local reproduction. 

1. 

Partnership/Association* 

If checked 

10. 

12. 

11. 
Describe other reasonable alternative routes and modes considered. 

Signature of Applicant 

b. Why were these alternatives not selected? 

Date 

c. Give explanation as to why it is necessary to cross Federal Lands 

14. List authorizations and pending applications filed for similar projects which may provide information to the authorizing agency. (Specify number, date, code, or name) 

15. Provide statement of need for project, including the economic feasibility and items such as: (a) cost of proposal (construction, operation, and maintenance); (b) estimated cost of next best alternative; and (c) expected public benefits. 

Describe probable effects on the population in the area, including the social and economic aspects, and the rural lifestyles. 

17. Describe likely environmental effects that the proposed project will have on: (a) air quality; (b) visual impact; (c) surface and ground water quality and quantity; (d) 

the control or structural change on any stream or other body of water; (e) existing noise levels; and (f) the surface of the land, including vegetation, permafrost, soil, 

and soil stability. 

18. Describe the probable effects that the proposed project will have on (a) populations of fish, plantlife, wildlife, and marine life, including threatened and endangered 

species; and (b) marine mammals, including hunting, capturing, collecting, or killing these animals. 

19. State whether any hazardous material, as defined in this paragraph, will be used, produced, transported or stored on or within the right-of-way or any of the right-of-way 

facilities, or used in the construction, operation, maintenance or termination of the right-of-way or any of its facilities. "Hazardous material" means any substance, 

pollutant or contaminant that is listed as hazardous under the Comprehensive Environmental Response, Compensation, and Liability Act of 1980, as amended, 42 U.S.C. 

9601 et seq., and its regulations. The definition of hazardous substances under CERCLA includes any "hazardous waste" as defined in the Resource Conservation and 

Recovery Act of 1976 (RCRA), as amended, 42 U.S.C. 9601 et seq., and its regulations. The term hazardous materials also includes any nuclear or byproduct material as defined by the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2011 et seq. The term does not include petroleum, including crude oil or any fraction thereof that 

is not otherwise specifically listed or designated as a hazardous substance under CERCLA Section 101(14), 42 U.S.C. 9601(14), nor does the term include natural gas. 

20. Name all the Department(s)/Agency(ies) where this application is being filed. 

Title 18, U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any department or agency of the United 

States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction. 

(Continued on page 3) (SF -299, page 2)

13a. 

16. 

I HEREBY CERTIFY, That I am of legal age and authorized to do business in the State and that I have personally examined the information contained in the application and

believe that the information submitted is correct to the best of my knowledge.
APPLICATION FOR TRANSPORTATION AND UTILITY SYSTEMS 

AND FACILITIES ON FEDERAL LANDS 

GENERAL INFORMATION 

ALASKA NATIONAL INTEREST LANDS 

This application will be used when applying for a right-of-way, permit, 

license, lease, or certificate for the use of Federal lands which lie within 

conservation system units and National Recreation or Conservation Areas as defined in the Alaska National Interest Lands Conservation Act. 

Conservation system units include the National Park System, National 

Wildlife Refuge System, National Wild and Scenic Rivers System, 

National Forest Monuments. 

Transportation and utility systems and facility uses for which the 

application may be used are: 

1. Canals, ditches, flumes, laterals, pipes, pipelines, tunnels, and other 

systems for the transportation of water. 

2. Pipelines and other systems for the transportation of liquids other than 

water, including oil, natural gas, synthetic liquid and gaseous fuels, 

and any refined product produced therefrom. 

3. Pipelines, slurry and emulsion systems, and conveyor belts for 

transportation of solid materials. 

4. Systems for the transmission and distribution of electric energy. 

5. Systems for transmission or reception of radio, television, telephone, 

telegraph, and other electronic signals, and other means of 

communications. 

6. Improved rights-of-way for snow machines, air cushion vehicles, and 

all-terrain vehicles. 

7. Roads, highways, railroads, tunnels, tramways, airports, landing 

strips, docks, and other systems of general transportation. 

National Trails System, National Wilderness Preservation System, and 

This application must be filed simultaneously with each Federal 

department or agency requiring authorization to establish and operate 

your proposal. 

In Alaska, the following agencies will help the applicant file an application and identify the other agencies the applicant should contact 

and possibly file with: 

Department of Agriculture 

Regional Forester, Forest Service (USFS) 

Federal Office Building, P.O. Box 21628 

Juneau, Alaska 99802-1628

Telephone: (907) 586-7847 (or a local Forest Service Office) 

Department of the Interior 

Bureau of Indian Affairs (BIA) 

Juneau Area Office 

9109 Mendenhall Mall Road, Suite 5, Federal Building Annex 

Juneau, Alaska 99802 

Telephone: (907) 586-7177 

Bureau of Land Management (BLM)

222 West 7th Ave., Box 13 

Anchorage, Alaska 99513-7599 

Telephone: (907) 271-5477 (or a local BLM Office) 

National Park Service (NPS) 

Alaska Regional Office, 2525 Gambell St., Rm. 107 

Anchorage, Alaska 99503-2892 

Telephone: (907) 257-2585 

U.S. Fish &Wildlife Service (FWS)

Office of the Regional Director 

101 1 East Tudor Road 

Anchorage, Alaska 99503 

Telephone: (907) 786-3440 

Note-Filings with any Interior agency may be filed with any office noted 

above or with the: Office of the Secretary of the Interior, Regional 

Environmental Officer, Box 120, 1675 C Street, Anchorage, Alaska 

99513. 

(For supplemental, see page 4) 

Department of Transportation 

Federal Aviation Administration 

Alaska Region AAL- 4,222 West 7th Ave., Box 14 

Anchorage, Alaska 99513-7587 

Telephone: (907) 271-5285 

- The Department of Transportation has established the above 

central filing point for agencies within that Department. Affected 

agencies are: Federal Aviation Administration (FAA), Coast Guard 

(USCG), Federal Highway Administration (FHWA), Federal Railroad 

Administration (FRA). 

OTHER THAN ALASKA NATIONAL INTEREST LANDS 

Use of this form is not limited to National Interest Conservation Lands of 

Alaska. 

Individual departments/agencies may authorize the use of this form by 

applicants for transportation and utility systems and facilities on other 

Federal lands outside those areas described above. 

For proposals located outside of Alaska, applications will be filed at the 

local agency office or at a location specified by the responsible Federal 

agency. 

SPECIFIC INSTRUCTIONS 

not listed are self-explanatory) 

Item 

7 Attach preliminary site and facility construction plans. The 

responsible agency will provide instructions whenever specific 

plans are required. 

Generally, the map must show the section(s), township(s), and 

within which the project is to be located. Show the 

proposed location of the project on the map as accurately as possible. Some agencies require detailed survey maps. The 

responsible agency will provide additional instructions. 

9, 10, and 12 - The responsible agency will provide additional 

instructions. 

13 Providing information on alternate routes and modes in as much 

detail as possible, discussing why certain routes or modes were rejected and why it is necessary to cross Federal lands will assist 

the agency(ies) in processing your application and reaching a final decision. Include only reasonable alternate routes and 

modes as related to current technology and economics. 

14 The responsible agency will provide instructions. 

15 Generally, a simple statement of the purpose of the proposal will 

be sufficient. However, major proposals located in critical or sensitive areas may require a full analysis with additional specific 

information. The responsible agency will provide additional 

instructions. 

16 through 19 - Providing this information in as much detail as possible will assist the Federal agency(ies) in processing the 

application and reaching a decision. When completing these 

items, you should use a sound judgment in furnishing relevant 

information. For example, if the project is not near a stream or other body of water, do not addressthis subject. The responsible 

agency will provide additional instructions. 

Application must be signed by the applicant or applicant's 

authorized representative. 

8 

If additional space is needed to complete any item, please put the 

information on a separate sheet of paper and identify it as "Continuation of Item". 

(SF-299, page 3)

NOTE 

(Items 

 ranges 
SUPPLEMENTAL 

NOTE: CHECK APPROPRIATE The responsible agency(ies) will provide additional instructions 

a. Articles of Incorporation 

b. Corporation Bylaws 

- PRIVATE CORPORATIONS ATTACHED FILED* 

c. A certification from the State showing the corporation is in good standing and is entitled to operate within the State. 

d. Copy of resolution authorizing filing 

e. The name and address of each shareholder owning 3 percent or more of the shares, together with the number and percentage of any 

class of voting shares of the entity which such shareholder is authorized to vote and the name and address of each affiliate of the entity 

together with, in the case of an affiliate controlled by the entity, the number of shares and the percentage of any class of voting stock of 

that affiliate owned, directly or indirectly, by that entity, and in the case of an affiliate which controls that entity, the number of shares 

and the percentage of any class of voting stock of that entity owned, directly or indirectly, by the affiliate. 

f. If application is for an oil or gas pipeline, describe any related right-of-way or temporary use permit applications, and identify 

previous applications 

b. Proof of organization 

d. If application is for an oil or gas pipeline, provide information required by Item "I-f" and "I-g" above. 

c. Copy of Bylaws 

d. Copy of resolution authorizing filing 

e. If application is for an oil or gas pipeline, provide information required by Item "I-f" and "I-g" above. 

a. Articles of association, if any 

b. If one partner is authorized to sign, resolution authorizing action is 

c. Name and address of each participant, partner, association, or other 

(Continued on page 5) (SF-299, page 4) 

g. If application is for an oil and gas pipeline, identify all Federal lands by agency impacted by proposal. 

II - PUBLIC 1 CORPORATIONS 

a. Copy of law forming corporation 

III - PARTNERSHIP OR OTHER UNINCORPORATED ENTITY 

* If the required information is already filed with the agency processing this application and is current, check block entitled "Filed." Provide the file identification 

information (e.g., number, date, code, name). If not on file or current, attach the requested information. 

I

BLOCK 
NOTICES

NOTE: This applies to the Department of the Interior/Bureau of Land Management (BLM). 

The Privacy Act of 1974 provides that you be furnished with the following information in connection with the 

information provided by this application for an authorization. 

AUTHORITY: 16 U.S.C. 310 and 5 U.S.C. 301. 

PRINCIPAL PURPOSE: The primary uses of the records are to facilitate the (1) processing of claims or 

applications; (2) recordation of adjudicative actions; and (3) indexing of documentation in case files supporting 

administrative actions. 

ROUTINE USES: BLM and the Department of the Interior (DOI) may disclose your information on this form: (1) to 

appropriate Federal agencies when concurrence or supporting information is required prior to granting or acquiring a 

right or interest in lands or resources; (2) to members or the public who have a need for the information that is 

maintained by BLM for public record; (3) to the U.S. Department of Justice, court, or other adjudicative body when 

DOI determines the information is necessary and relevant to litigation; (4) to appropriate Federal, State, local, or 

foreign agencies responsible for investigating, prosecuting violation, enforcing, or implementing this statute, 

regulation, or order; and (5) to a congressional office when you request the assistance of the Member of Congress in 

writing. 

EFFECT OF NOT PROVIDING THE INFORMATION: Disclosing this information is necessary to receive or 

maintain a benefit. Not disclosing it may result in rejecting the application. 

The Paperwork Reduction Act of 1995 requires us to inform you that: 

The Federal agencies collect this information from applicants requesting right-of-way, permit, license, lease, or 

certifications for the use of Federal Lands. 

Federal agencies use this information to evaluate your proposal. 

No Federal agency may request or sponsor and you are not required to respond to a request for information which 

does not contain a currently valid OMB Control Number. 

BURDEN HOURS STATEMENT: The public burden for this form is estimated at 25 hours per response including 

the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct 

comments regarding the burden estimate or any other aspect of this form to: U.S. Department of the Interior, Bureau 

of Land Management (1004-0189), Bureau Information Collection Clearance Officer (WO-630) 1849 C Street, 

N.W., Mail Stop 401 LS, Washington, D.C. 20240. 

A reproducible copy of this form may be obtained from the Bureau of Land Management, Land and Realty Group, 

1620 L Street, N.W., Rm. 1000 LS, Washington, D.C. 20036. 

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(SF – 299, page 5)