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Instru ctions: 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 3510-1 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, Commerc ial, Mining, and Silvicultural Operations ( not included in this package ), and
2D. New Manufacturing, Commerci al, 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 dis posal 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 Deterior ation 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 ha s 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 generalinformation 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 list ed above also are subject to EPA administered environmental permi t 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 Mexi co, 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 contactthe 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 FileBecause 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 expires 2

, or 180 days prior to startup if you are a new facility. 2C ( NPDES ) . . . . . . . . . . 180 days before your present NPDES permit expires 2

. 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 befo re 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 anew 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 a pplication 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 app licable, 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 necess ary 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 as sistance 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 themarks. 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 ISpace 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 cont act 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 determi ne 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 3which 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 wh o can be contacted by reviewing offices if necessary.

Item VGive 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., sectionnumber or quarter section number from county records or at intersection of Rts. 425 and 22 ).

Item VII List, in descending order of signifi cance, 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 describ ing 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 Govern ment Printing Office, Washington, D.C. Use the current edition of the manual. If you have any questions concerning the appropriate SIC code fo r 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 presentl y effective permit issued to the facility for each program or, if you have previously filed an applicationbut 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 locati on 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 facilitysite, 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 specificati ons. 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 illustrati on 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 seve re 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 writingor 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 th at “Any person who knowingly makes any false statement, representation, or certification in any application, . . . shall upon convic tion, 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 andRecovery Act provides for a fine up to $25,000 per day or imprisonment up to one year, or both, for a first conviction fo r 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, t he 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 office r 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 requirementsmay 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 properlyfunctioning 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 otherthan as a means of transportation, such as when the vessel is being used as an energy or mining fa cility, a storage facility, or a seafood processing facility, or is secured to the bed of the ocean, contiguous zone, or waters of t he 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 bythe 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 standardspromulgated 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 otherwiserequired 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 tak en 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 runo ff from orchards, cultivatedcrops, pastures, range lands, and forest lands. However, the discharges listed below do require NP DES permits. Definitions of the terms listed below are contained in the Glossary section of these instructions.

1. Discharges from Concentrate d Animal Feeding Operations. ( See Glossary for definitions of “animal feeding operations” and “concentrated animal feeding operati ons.” Only the latter require permits. )
2. Discharges from Concentra ted 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 ex cluded 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

Ow ners 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 tan ks 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 incr ease 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 pa rts of the Consolidated Permits Program. If you have any quest ions 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 grow th, 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 theforms; 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 harvest able 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, us ing a method of plan or operation ( including, but not limited to, physical confinement ) which, on the basis of reliable scientific evidenc e, 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 t han 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 asunclassifiable with respect to that pollutant due to insufficient Information.
BEST MANAGEMENT PRACTICES ( BMP ) means schedules of activities, prohibitions of prac tices, maintenance procedures, and other management practices to prevent or reduce the pollution of

w aters 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 Di rector designates as such on a case-by-case basis:

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

1. 1,000 slaughter or feeder cattle,
2. 700 mature dairy cattle ( whether milked or dry cows ),
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 an imal 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 t he 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 in to waters of the United Statesfrom: Surface runoff which is collected or channelled by man; Discharges through pipes, sewers, or other conveyances owned by a State, municipality, or other per son 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 w ill remain after closure.
EFFLUENT LIMITATION means any restriction imposed by the Director on quantities, discharge ra tes, and concentrations of pollutants which are discharged from point sources into waters of the United States, the waters of th e 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 Managementfacility 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 c ancelled or modified without substantial loss, for construction of t he facility to be completed within a reasonable time.

( NOTE: This definition reflects th e 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 enc ourages 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 Aof 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 substanc e 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 th e land surface in a zone of saturation.

HAZARDOUS SUBSTANCE means an y 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, stru ctures, 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 Statehazardous 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 surfac e; 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, moni toring, 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 definit ion 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 processi ng vessel, or aggregate plant that begins discharging at a location fo r which it does not have an existing permit.
NEW HWM FACILITY means a Hazardous Waste Management facility which began operation or fo r 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 ( ot her 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 pr ivate 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 combusti on-reaction in an enclosed device to provide sufficient residence ti me 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, lic ense, 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 facilit y 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 limit ed to any pipe, ditch, channel, tunnel, conduit, well, discrete fissur e, container, rolling stock, concentrated animal feeding operation, vessel or other floating craft fromwhich 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 mate rials, 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 cove red by the Atomic Energy Act are those encompassed in its definition of source, byproduct, or special nuclear materials. Exampl es 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 di rect 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 rela ted to rock crushing, gravel washing, log sorting, or log stor age facilities which are operated in connection with silvicultural activi ties and from which pollutants are discharged into waters of the United States. This term does notinclude 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 C WA ).
STATIONARY SOURCE ( in the PSD program ) means any building, structure, facility, or installati on 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 o ne 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 inje ction 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 hazar dous 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 dev ice which uses elevated temperature as the primary means to change the chemical, physical, or biological character or compositi on of the hazardous waste. Examples of thermal treatment proce sses 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 haz ardous 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; safe r 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, improper ly 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, ormay 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 orcould 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 identif ied 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 exclusionapplies 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 tosupport, and that under normal circumstances do support, a prevalence of vegetation typically adapted for life in saturated soil conditions. Wetlands generally incl ude 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 answ er “yes” to any questions, you must submit this form and the supplemental form listed in the parenthesis following the quest ion. Mark “X” in the box in the third c olumn 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 anim al 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 pot entially 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 REVERSECONTINUED 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 ENVI RONMENTAL 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 ext ending to at least one mile beyond property boundaries. The map mus t show the outline of the facility, the location of each of its existing and proposed intake and dischar ge structures, each of its haza rdous 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 informati on submitted in this applicati on and all attachments and that, based on my inquiry of those persons immediately responsible for obtaining t he 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 info rmation, including the possi bility of fine and imprisonm ent.

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 docum ent that allows you to type your information directly into the form, print it, and save the completed form.

Note: This f orm can be viewed and saved only using Adobe Acrobat Reader version 7.0 or higher, or if you have the full Adobe Professional version.

Instru ctions: 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 c onsists of a "Basic Application Information" packet and a "Supplemental Application Information" packet. The Ba sic 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 questi ons A.1 through A.8. A treatment works that discharges effluent to surface waters of the Un ited 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 comple te 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 author ity to submit results of toxicity testing.

F. Industrial User Discharges and RCRA/CERCLA Wastes. A treatment works that accept s process wastewater from any significant industrial users (SIUs) or receives RCRA or CERC LA wastes must complete Part F (Industrial User Discharges and RCRA/CERCLA Wastes). SIUs are defined as:
1. All industrial users subject to Catego rical Pretreatment Standards under 40 Co de 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 av erage 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 sy stem 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 (muni cipal, private, etc.).

Name Population Served Type of Collection System Ownership

Total population servedEPA 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 event ually flows through) Indian Country?

Yes No

A.6. Flow. Indicate the design flow rate of the treatment plant (i.e., t he wastewater flow rate that the plant was built to handle). Al so provide the average daily flow rate and maximum daily flow rate for each of th e 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 treat ment 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 trans port treated or untreated wastewater to another treatment works? Yes NoEPA 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 t he treatment works is discharged or transported to the other treatm ent 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 treat ment works into the receiving facility. mgd

e. Does the treatment works discharge or dispos e 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 locati on 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 informat ion on combined sewer overflows in this section. If you answered "no" to question A.8.a , go to Part B, “Additional Application Information for Applic ants 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 shor e (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 Servic e 14-digit watershed code (if known):

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

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

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

acute cfs chronic ______________ cfs

e. Total hardness of receiving stream at critical low flow (if applicable): _______________ mg/l of CaCO 3EPA 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 BOD 5 removal or Design CBOD 5 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 t he 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 a part.

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 COMPLETEEPA 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 exte nding 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 doe s 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 plan t. 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, st ored, and/or disposed.

B.3. Process Flow Diagram or Schematic. Provide a diagram showing the processes of t he treatment plant, including all bypass piping and all backup power sources or redundancy in the system. Also provide a water balance showing all tr eatment units, including disinfec tion (e.g, chlorination and dechlorination). The wate r balance must show daily average flow rates at influent and discharge points and ap proximate 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 re sponsibility 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 unc ompleted implementation schedule or uncompleted plans for improvements that will affect the wastewat er treatment, effluent quality, or design capacity of the treat ment 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 ou tfall that is covered by this implementation schedule.

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

____Yes ____NoEPA 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 completi on 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 e ffluent testing data for the following parameters. Provide the ind icated effluent testing required by the permitting authority fo r 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 Pa rt 136 methods. In addition, this data must comply with QA/QC requi rements of 40 CFR Part 136 and other appropriate QA/QC requirement s 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 COMPLETEEPA 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 Over view. Indicate below which pa rts of Form 2A you have completed and are submitting. By signi ng 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 attach ments were prepared under my direction or supervision in accord ance with a system designed to assure that qualified personnel properly gather and evaluat e 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 m y knowledge and belief, true, accurate, and complete. I am aware that there ar e significant penalties for submi tting false information, includ ing 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 othe r information necessary to assess wastewater treatment practi ces 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 other wise 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 th e permitting authority for each outfall through which effluent is discharged . Do not include information on combined sewer overfl ows 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 requi rements 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 minim um, 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 di scharging 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 CaCO 3 )

Use this space (or a separate sheet) to provide inform ation 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 di scharging 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-TETRA CHLORO-ETHANE

TETRACHLORO-ETHYLENE

TOLUENEEPA 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 di scharging 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)PYRENEEPA 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 di scharging 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-DIPHENYLHYDRAZINEEPA 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 di scharging 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 writ er.



# END OF PART D. REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM 2A YOU MUST COMPLETEEPA 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 chro nic 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 pretreatm ent program (or those that are required to have one under 40 CFR Part 403); or 3) POTW s 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 applicatio n, provided the results show no appreciable toxicity, and te sting for acute and/or chronic toxicity , depending on the range of receiving water dilution. Do not include information on combined sewer overflows in this se ction. 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 13 6 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 to xicity tests from the past four and one-half years. If a whole effluent toxicity test conducted during the past four and one-hal f years revealed toxicity, provide any in formation 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 i nformation requested in question E.4 for previously submitted information. If EPA methods were not used, report the reasons for using alt ernate methods. If test summaries are available that contain all of the information requested below, th ey may be submitted in place o f Part E. If no biomonitoring data is required, do not complete Part E. Re fer 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 to xicity 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, indi cate the number of grab samples used.

24-Hour composite

Grab

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

Before disinfection

After disinfection

After dechlorinationEPA 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 pr ocess 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 a ll concentrations in the test series.

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

pH

Salinity

Temperature

Ammonia

Dissolved oxygen

l. Test Results.

Acute:

Percent survival in 100% effluent % % %

LC 50

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 % % %

IC 25 % % %

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, prov ide the dates the information wa s submitted to the permitting a uthority 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 was tes 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 disc harge 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 thro ugh F.8 and provide the information requested for each SIU.

F.3. Significant Industrial User Information. Provide the name and address of each SIU dischar ging 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 di scharged into the collection system in gallons per day (gpd) and whether the dischar ge is continuous or intermittent.
_____________ gpd (_____continuous or ______intermittent)

b. Non-process wastewater flow rate. Indicate the average dai ly volume of non-process wastewater flow discharged into the co llection 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 thr ee 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 am ount (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 notifi ed that it will) receive waste from remedial activities?
____Yes (complete F.13 through F.15.) ____No
Provide a list of sites and the requested informatio n (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/o r other remedial waste originates (or is expected to origina te in the next five years).

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

F.14. Pollutants. List the hazardous constituents that are received (or are expected to be receiv ed). 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 treat ed) 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 disc harge be) continuous or intermittent?
____Continuous ____Intermittent If inte rmittent, describe discharge schedule.

____________________________________________________________________________________________________ 

# END OF PART F. REFER TO THE APPLICATION OVERVIEW TO DETERMINE WHICH OTHER PARTS OF FORM 2A YOU MUST COMPLETEEPA 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., beac hes, 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 li nes, 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-di git 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 c aused by this CSO (e.g., permanent or intermittent beach closi ngs, permanent or intermittent shell fish bed closings, fish kills, fish advisories, other recreational loss, or violation of any ap plicable 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 docum ent that allows you to type your information directly into the form, print it, and save the completed form.

Note: This f orm can be viewed and saved only using Adobe Acrobat Reader version 7.0 or higher, or if you have the full Adobe Professional version.

Instru ctions: 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.For m

Appr oved OM B No. 2040- 0250 Appr oval expir e s 12- 15- 05

E P A I.D. NUM B E R ( 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 OPER ATIONS 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 Anim al Feeding Oper ation ( c om plete item s B, C, D, and Section I I )

“ 2. Concentrated Aquatic Animal Production Facility (complete items B, C, and section III) Owner/or Oper ator Nam e : 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: Na me of Integrator: Address of Integrator: ___________________________________________________________

_________________________________________________________ _____________________________

___________________ _____________________________________

_________________________ _______________________________

_________________________________________________

_______________________________________________

II. CONCENTRATED ANIMAL FEEDING OPERATION CHARACTERISTICS

A. TYPE AND NUMBER OF ANIMALS B. Manure, L itter and/or W a stewater Production and Use

2. ANIMALS a) How m u ch m a nure, 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/wast ewater?

____________________ acres

c) How many tons of manure or litter, or gallons of waste

water produced by the CAFO will be transferred annually to other per s ons? tons/gallons ( circle one) _____ _______

1. T Y PE NO. IN OPEN CONFINEMENT NO. HOUSED UNDER ROOF

“ Mature Dairy Cows

“ Dairy Heif ers

“ Veal Calves

“ Cattle (not dairy or veal)

“ Swine ( 55 lbs. or over )

“ Swine ( under 55 lbs. )

“ Horses

“ Sheep or Lam b s

“ Tu rk eys

E P A For m

3510- 2B ( 12- 02)For m

Appr oved OM B No. 2040- 0250 Appr oval expir e s 12- 15- 05

“ Ch ick e n s (Bro ilers)

“ Chickens ( L ay er s)

“ Ducks

“ Other Specify

___________

3

. TOTAL ANIMALS

C. “ TOPOGRAPHIC MAP

D. TYPE OF CONTAINMENT, STORAGE AND CAPACITY

1. T y pe of Containm ent T otal Capacity ( i n gallons)

“ L a goon

“ Holding Pond

“ E v apor ation Pond

“ Other : Specify

_______________

2. Repor t the total num ber of acr es contr i buting dr ainage: acr es

__________________________

3. T y pe of Stor age T otal Num b er of Days Total Capacity ( g allons/tons)

“ Anaer obic L a goon

“ Stor age L a goon

“ E v apor ation Pond

“ Abovegr ound Stor age T a nks

“ Belowgr ound Stor age T a nks

“ Roof ed Storage Shed

“ Concr e te Pad

“ I m per v ious 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 manage ment plan be deve loped? Date:

____________

D. The date of the last review or revisi on of the nutrient management plan. Date:

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

E P A For m

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 manage ment practices that are being implemente d at the facility to control runoff and pr otect water quality:

“ Buffers “ Setbacks “ Conservation tillage “ Constructed wetlands “ Infiltration field “ Grass filter “ Terrace

III. CONCENTRATED AQUATIC ANIMAL PR ODUCTION 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, gi ve the total weight produced b y 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. Repor t 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 informa tion submitted in this applicati on 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 pe nalties for submitting false information, in cluding the possibility of fine and imprisonment.

B. Phone No. ( )

C. Signature D. Date Signed

EPA Form 3510-2B (12-02)For m

Appr oved OM B No. 2040- 0250 Appr oval expir e s 12- 15- 05

INSTRUCTIONS

GENERAL Ite m 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 inform a tion on the ty pe of c onta i nm e n t a nd the c a p a c ity of the

co n t ai n m en t s t r u ct u r e ( s )

. 2

. Th e n u m b e r

o f

acr es t h at ar e d r ai n e d an d co l l ect ed i n t h e co n t ai n m en t
struc t ure (s). 3. Ide n tify the ty pe of stora g e for the m a nure , litte r a nd/or wa ste w a t e r

. G i ve the c a p a c ity of this stora g e in da y s a nd ga llons or tons. Ite m II-E Provide inform a tion c onc e r ning the sta t us of the de ve lopm e n t a n d im

ple m e n ta tion of a nutrie n t m a na ge m e nt pla n for the fa c ility . In those

cas es wh er e t h e n u t r i en t m a n a g e m e n t p l an h a s n o t b een co m p l e t e d

, provide an estimated date of development and implementation. If not R e fe r to the Form 1 instruc tions to de te rm ine whe r e to file this form

. la nd a pply i ng, de sc ribe the a lte rna tive use s of the m a nure , litte r a n d Item I-A See the note above and the General Instructi ons 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 lega l 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. w a ste w a t e r (e

. g

. , c o m posting, pe lle tiz ing, e n e r gy ge ne ra tion, e t c

. ). Ite m II-F Ch eck an y o f t h e i d en t i f i e d co n s er v a t i o n p r act i ces t h at ar e b e i n g im

ple m e n te d a t the fa c ility to c ontrol runoff a nd prote c t w a te r qua lity

. Ite m III Supply a ll inform a tion in Ite m III if y ou c h e c k e d (2) in Ite m I-A

. Ite m III-A O u tfa lls should be num be re d to c o rre spond w ith the m a p subm itte d in Ite m X I of Form 1. V a lue s give n for flow should be re pre s e n ta tive of

y our norm a l ope ra tion. T h e m a xim u m

da ily flow is the m a xim u m

m e a s ure d flow oc c u rring ove r a c a l e nda r da y

. T h e m a xim u m

30-da y flow is the a v e r a g e of m e a s ure d da ily flow ove r the c a l e nda r m onth of highe st flow

. T h e long-te rm a v e r a g e flow is the a v e r a g e of m e a s ure da ily f l o w s o v e r a cal en d a r year

. Ite m III-B Give the total num ber of discrete ponds or racew ays in your facility. U nde r “othe r , ” give a de sc riptive na m e of a n y struc t ure w h ic h is not a pond or a raceway but which results in discharge to wate rs of the United S t at es

. Ite m III-C Use nam e s for receiving water and source of water which correspond to the m a p subm itte d in Ite m XI of Form 1. Ite m III-D T h e na m e s of fish spe c i e s should be prope r, c o m m on, or sc ie ntific na m e s

as g i v e n i n s p eci al P u b l i cat i o n No . 6 o f t h e Am er i can F i s h er i e s S o ci et y. “A List of C o m m on a nd Sc ie ntific Na m e s of Fishe s from the Unite d Sta t e s a nd C a na da

. ” T h e va lue s give n for tota l w e ight produc e d by y our fa c ility pe r y e a r a nd the m a xim u m

w e ight pre s e n t a t a n y one tim e should be re pre s e n ta tive of y our norm a l ope ra tion. Ite m III-E T h e va lue give n for m a xim u m

m onthly pounds of food should be

re pre s e n ta tive of y our norm a l ope ra tion. Ite m IV The C l e a n Wa te r Ac t provide s for se ve re pe na ltie s for subm itting fa lse inform a tion on this a pplic a tion form

. Se c tion 309(C )(2) of the C l e a n Wa te r A c t provide s tha t “A ny pe rson

w ho know ingly m a ke s a n y fa lse sta t e m e n t, re pre s e n ta tion, or certification in any app lication...shall upon conviction, be punished by a fine of no m o re tha n $10, 000 or by im prisonm e n t for not m o re tha n six

m onths, 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. Pa p er Red u c t i o n Act No t i ce Th e Pu b l i c rep o r t i n g b u r d e n f o r t h i s co l l ect i o n o f i n f o rm a t i o n

es t i m a t e d t o a v era g e 4 h o u r s p er res p o n s e. Th e es t i m a t e i n cl u d e s t i m e f o r rev i e w i n g i n s t ru ct i o n s , s e a rch i n g ex i s t i n g d a t a s o u r ces , gathe r i ng and m a intaining the ne e d e d data, and c o m p le ting and

rev i e w i n g t h e co l l ect i o n o f i n f o rm a t i o n
. S e n d co m m e n t s reg a r d i n g the bur de n e s tim a te or any othe r aspe c t of this c o lle c t ion of infor m ation to the c h ie f, Infor m ation P o lic y B r anc h (P M-223), U

. S. E n vir o nm e n tal P r ote c tion A g e n c y , 1200 P e nnsylvania A v e nue , N

. W. , Washington, D

. C

. 20460, and the O ffic e of Infor m ation and R e gulator y A f air s , O ffic e of Manage m e nt and B udge t , Washington, D.C. 20503, m a rk ed Attention: Desk Officer for EPA.

E P A For m

3510- 2B ( 12- 02)

# Disclaimer

This is an updated PDF docum ent that allows you to type your information directly into the form, print it, and save the completed form.

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Instru ctions: 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)

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## 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 colle ction of information. Send

comm ents 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 cl aim 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, includi ng 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 s hould 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 electric al energy consumed by smelting furnace.” An example of a guideli ne 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 fac ility 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 bas ed on actual daily production and not on design capacity or on predict ions 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 duri ng the duration of the permit.

Item IV-A If you check “yes” to this question, co mplete 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 materi als, 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 pe sticides, 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 de termined 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 char acterize 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 s pecific questions. Any specific requirements contained in the app licable 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 disc harges 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 ti me 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 prev ious 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, processe s, 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, th e 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 samp le holding time, preservation techniques, and the quality control m easures 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 li ter ton....... .....tons (English tons) ppb..........parts per billion mg

................... ....milligrams ug/l ...micrograms per lite r 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 s heet 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 c ooling 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 discuss ion 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 coo ling water or storm runoff. You must report quantitative data if the pollutant(s) in question is limited in an effluent limitations guideline ei ther 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 ca tegory or subc ategory 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 Chem icals 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 c hallenge 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 mu st 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 thres holds 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 fa cilities 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 Gener al 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 meas urable baseline deflection at the retention time of TCDD” or “a me asurable 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 devel opment 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 opera ting 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 c ontribute 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 approx imate 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)

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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 haz ardous substances. A discharge of a particular substance may be exempted if the origin, source, and amount of the discharged substanc es are identified in the NDPES permit application or in the per mit, 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 additional ly 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 pr oduction 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 fo r severe penalties for submitting false information on this application form.
Section 309(c)(2) of the Clean Wate r Act provides that “Any person who knowingly makes any false statement, representation, or certification in any applicati on,... 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 responsi ble corporate official means (i) a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business f unction, or any other person who performs similar policy- or de cision-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 assignm ent 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 office r or ranking elec ted official. For purposes of this section, a princi pal executive officer of a Federal Agency includes (i) the chief executive officer of the Agency, or (ii) a senior executive officer havin g 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 Oxidati on 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 ( Chlo r i ne ) 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–Denitrificati on 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 Digesti on 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 Thick ening 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 FRACTION 1 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 electroni c 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 m anufacturing .......................................... 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 m anufacturing............................................. X X X X Paint and ink formul ation .......................................................... 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 materi als 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 pr ocessing...................................................... 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 A PPLICANTS 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 Fibe r Preparation Dyeing Washing Drying

Grit Separato r 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 Rive r Municipal Water Supply

30,000 GPD Blue Rive r
10,000 GPD Cooling Wate r

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 70,000 GPD + Stormwater Stormwate r Max: 20,000 GPD

Schematic of Water Flow Brown Mills, Inc. Cit y , Count y , StatePlease 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 longit ude of its location to the nearest 15 sec onds and the name of the receiving water

. B. LATITUDE C. LONGITUDE A. OUTFALL NUMBER ( 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 facili ty. 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 ave rage 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 operatio ns contributing wastewater to the effluent, including process wa stewater, sanitary wastewater, cooling water,

and storm water runoff; (2) The average flow contributed by each operation; and (3) The treatment received by the wastewater. C ontinue on additional sheets if
necessary.
2. OPERATION(S) CONTRIBU TING FLOW 3. TREATMENT1. 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 REVERSECONTINUED FROM THE FRONT
C. Except for storm runoff, leaks, or spi lls, 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 t he quantity which represents an actual m easurement of your level of production, e xpressed 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 authorit y to meet any implementation sc hedule for the construction, upgr ading or operations of wastewater treatment equipment or practices or any other environmental progr ams which may affect the dischar ges described in this applicat ion? This includes, but is not limited to, permit conditions, administrative or enfor cement orders, enforcement compliance schedul e letters, stipulations, court orders, a nd grant or loan conditions. YES ( complete the following table ) NO ( go to Item IV-B )

2. AFFECTED OUTFALLS 4. FINAL COMPLIANCE DATE 1. IDENTIFICATION OF CONDITION, 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 o r planned schedules for construction.

MARK “X” IF DESCRIPTION OF ADDI TIONAL CONTROL PROGRAMS IS ATTACHED

EPA Form 3510-2C (8-90) PAGE 2 of 4 CONTINUE ON PAGE 3CONTINUED 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 se t of tables for each outfall – Annotate the outfall number in th e 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 y ou know or have reason t o 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 analyt ical 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 inte rmediate 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 REVERSECONTINUED 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 y our 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 perfor med 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 accord ance with a system desi gned to assure that qualified personnel properly gather and evaluate the information submitted. Base d on my inquiry of the person or persons who ma nage the system or those persons directly responsible for gathering the info rmation, the information s ubmitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting fals e information, including the possibility of fine and imprisonment for knowing viol ations. 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 4PLEASE PRINT OR TYPE IN THE UNSHADED AREAS ONLY. You may report someor all of this informationon 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)OUTFALL NO.PART A –You must provide the results of at least one analysis forevery pollutant in this table. Complete one table for each outfall. See instructions for additional details.2. EFFLUENT3. UNITS(specify if blank)4. INTAKE(optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG. VALUE(if available)a. LONG TERMAVERAGE VALUE1. POLLUTANT(1)CONCENTRATION (2) MASS(1)CONCENTRATION (2) MASS (1) CONCENTRATION (2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION (2) MASSb. NO. OFANALYSESa. Biochemical OxygenDemand(BOD)b. Chemical OxygenDemand (COD)c. Total Organic Carbon(TOC)d. Total SuspendedSolids (TSS)e. Ammonia (as N)f. FlowVALUE VALUE VALUEVALUEg. Temperature(winter)VALUE VALUE VALUE°CVALUEh. Temperature(summer)VALUE VALUE VALUE°CVALUEi. pHMINIMUM MAXIMUM MINIMUM MAXIMUMSTANDARD UNITSPART 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 column 2a for any pollutant which is limited eitherdirectly, or indirectly but expressly, in an effluent limitationsguideline, you must provide the results of at least one analysis for that pollutant. For other pollutants for which you mark column 2a, you must providequantitative 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. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG. VALUE(if available)a. LONG TERM AVERAGEVALUE1. POLLUTANTANDCAS NO.(if available)a.BELIEVEDPRESENTb.BELIEVEDABSENT(1)CONCENTRATION (2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESa. Bromide(24959-67-9)b. Chlorine, TotalResidualc. Colord. Fecal Coliforme. Fluoride(16984-48-8)f. Nitrate-Nitrite(as N)EPA Form 3510-2C (8-90)PAGE V-1CONTINUE ON REVERSEITEM V-B CONTINUED FROM FRONT2. MARK “X” 3. EFFLUENT 4. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG. VALUE(if available)a. LONG TERMAVERAGE VALUE1. POLLUTANTANDCAS NO.(if available)a.BELIEVEDPRESENTb.BELIEVEDABSENT(1)CONCENTRATION (2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESg. Nitrogen,Total Organic (asN)h. Oil andGreasei. Phosphorus(as P), Total(7723-14-0)j. Radioactivity(1) Alpha, Total(2) Beta, Total(3) Radium,Total(4) Radium 226,Totalk. Sulfate(as SO4)(14808-79-8)l. Sulfide(as S)m. Sulfite(as SO3)(14265-45-3)n. Surfactantso. 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-2CONTINUE ON PAGE V-3CONTINUED FROM PAGE 3 OF FORM 2-CEPA I.D. NUMBER (copy from Item 1 of Form 1)OUTFALL NUMBERPART C - If you are a primary industry and this outfall contains process wastewater, refer to Table2c-2 in the instructions todetermine which of the GC/MS fractions you must test for. Mark “X” in column 2-a for all such GC/MSfractions 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 wastewater outfalls, and nonrequired GC/MSfractions), 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 markcolumn 2a for any pollutant, you mustprovide the results of at least one analysis for that pollutant. If you mark column 2b for any pollutant, you must provide theresults of at least one analysis for that pollutant ifyou know or have reason to believe it will bedischarged in concentrations of 10 ppb or greater. If you markcolumn 2b for acrolein, acrylonitrile, 2,4 dinitrophenol, or 2-methyl-4, 6 dinitrophenol, you must provide the results of at least one analysis for each of thesepollutants which you know or have reason to believe that you discharge in concentrations of 100 ppb or greater. Otherwise, forpollutants for which you mark column 2b, you must either submit at least one analysis orbriefly 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 pages) for each outfall. See instructions foradditional details and requirements.2. MARK “X” 3. EFFLUENT 4. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG.VALUE (if available)a. LONG TERMAVERAGE VALUE1. POLLUTANTANDCAS NUMBER(if available)a.TESTINGREQUIREDb.BELIEVEDPRESENTc.BELIEVEDABSENT(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESMETALS, CYANIDE, AND TOTAL PHENOLS1M. 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,TotalDIOXIN2,3,7,8-Tetrachlorodibenzo-PDioxin (1764-01-6)DESCRIBE RESULTSEPA Form 3510-2C (8-90)PAGE V-3CONTINUE ON REVERSECONTINUED FROM THE FRONT2. MARK “X” 3. EFFLUENT 4. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG.VALUE (if available)a. LONG TERMAVERAGE VALUE1. POLLUTANTANDCAS NUMBER(if available)a.TESTINGREQUIREDb.BELIEVEDPRESENTc.BELIEVEDABSENT(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESGC/MS FRACTION – VOLATILE COMPOUNDS1V. 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. CarbonTetrachloride(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. MethylBromide (74-83-9)21V. MethylChloride (74-87-3)EPA Form 3510-2C (8-90)PAGE V-4CONTINUE ON PAGE V-5CONTINUED FROM PAGE V-42. MARK “X” 3. EFFLUENT 4. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG.VALUE (if available)a. LONG TERMAVERAGE VALUE1. POLLUTANTANDCAS NUMBER(if available)a.TESTINGREQUIREDb.BELIEVEDPRESENTc.BELIEVEDABSENT(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESGC/MS FRACTION – VOLATILE COMPOUNDS (continued)22V. MethyleneChloride (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 COMPOUNDS1A. 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-5CONTINUE ON REVERSECONTINUED FROM THE FRONT2. MARK “X” 3. EFFLUENT 4. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG.VALUE (if available)a. LONG TERMAVERAGE VALUE1. POLLUTANTANDCAS NUMBER(if available)a.TESTINGREQUIREDb.BELIEVEDPRESENTc.BELIEVEDABSENT(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESGC/MS FRACTION – BASE/NEUTRAL COMPOUNDS1B. 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-BromophenylPhenyl Ether(101-55-3)15B. Butyl BenzylPhthalate (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-6CONTINUE ON PAGE V-7CONTINUED FROM PAGE V-62. MARK “X” 3. EFFLUENT 4. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG.VALUE (if available)a. LONG TERMAVERAGE VALUE1. POLLUTANTANDCAS NUMBER(if available)a.TESTINGREQUIREDb.BELIEVEDPRESENTc.BELIEVEDABSENT(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESGC/MS FRACTION – BASE/NEUTRAL COMPOUNDS (continued)22B. 1,4-Dichlorobenzene (106-46-7)23B. 3,3-Dichlorobenzidine (91-94-1)24B. DiethylPhthalate (84-66-2)25B. DimethylPhthalate(131 -11-3)26B. Di-N-ButylPhthalate (84-74-2)27B. 2,4-Dinitrotoluene (121-14-2)28B. 2,6-Dinitrotoluene (606-20-2)29B. Di-N-OctylPhthalate (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-7CONTINUE ON REVERSECONTINUED FROM THE FRONT2. MARK “X” 3. EFFLUENT 4. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG.VALUE (if available)a. LONG TERMAVERAGE VALUE1. POLLUTANTANDCAS NUMBER(if available)a.TESTINGREQUIREDb.BELIEVEDPRESENTc.BELIEVEDABSENT(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESGC/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– PESTICIDES1P. 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. EndosulfanSulfate(1031-07-8)14P. Endrin(72-20-8)15P. EndrinAldehyde(7421-93-4)16P. Heptachlor(76-44-8)EPA Form 3510-2C (8-90)PAGE V-8CONTINUE ON PAGE V-9CONTINUED FROM PAGE V-8EPA I.D. NUMBER (copy from Item 1 of Form 1)OUTFALL NUMBER2. MARK “X” 3. EFFLUENT 4. UNITS5. INTAKE (optional)a. MAXIMUM DAILY VALUEb. MAXIMUM 30 DAY VALUE(if available)c. LONG TERM AVRG.VALUE (if available)a. LONG TERMAVERAGE VALUE1. POLLUTANTANDCAS NUMBER(if available)a.TESTINGREQUIREDb.BELIEVEDPRESENTc.BELIEVEDABSENT(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASS(1)CONCENTRATION(2) MASSd. NO. OFANALYSESa. CONCEN-TRATION b. MASS(1)CONCENTRATION(2) MASSb. NO. OFANALYSESGC/MS FRACTION– PESTICIDES (continued)17P. HeptachlorEpoxide(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 docum ent that allows you to type your information directly into the form, print it, and save the completed form.

Note: This f orm can be viewed and saved only using Adobe Acrobat Reader version 7.0 or higher, or if you have the full Adobe Professional version.

Instru ctions: 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 17 th 

## 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. Ho wever, 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 s hould 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 y ou 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. Inaddition, 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 di tch, 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 (operat ions contributing to the flow), and estimate an average flow from eac h 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 drawi ng should show the route taken by water in your proposed facility form intake to discharge. Show all sources of wastewater, incl uding 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, pr ocess 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 re fers to those goods which the proposed facility will produce, not to “wastewater” production. This information is only necessary w here production-based new source performance standards (NSPS) or e ffluent guidelines apply to your facility. Your estimated produc tion figures should be based on a realistic projection of actual da ily 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 sche dule or capacity, the applicant may report alternative production estimate s 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 po llutant 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 studi es 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 yo u 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 paramet er 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 millio n lbs

................................. pounds mg/l .............milligrams per liter ton .............. t ons (English tons) ppb................... parts per billi on mg ............................m illigrams ug/l............ micrograms pe r liter g .....................................grams kg.............................. kil ograms T ............... tonnes (metric tons)

Source In providing the estimates, use t he 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 requesti ng 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 pa rticular 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 gro ss 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 c ontact 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 fo r additional information which you believe would be useful in setting permit li mits, such as additional sampling. Any response is optional.

Item VIII The Clean Water Act provides fo r severe penalties for submitting false information on this application form.
Section 309(c)(2) of the Clean Wate r 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 f unctions 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 office r or ranking elec ted official. For purposes of this section, a princi pal 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 Oxidati on 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 ( Chlo r i ne ) 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–Denitrificati on 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 Digesti on 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 Thick ening 5–V . . . . . . . . . . Vibration 5–K . . . . . . . . . . Freezing 5–W . . . . . . . . . . Wet Oxidation 5–L . . . . . . . . . . Gravity ThickeningEPA 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 S0 4 ) Total Residual Chlorine Sulfide (as S) Color Sulfite (as S0 3 ) 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-TrichlorophenolEPA 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

Isoprene Asbestos Isopropanolamine dodecylbenzenesulfonate
Kelthane 

## HAZARDOUS SUBSTANCES 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-Trichlorophe noxyacetic 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) Fibe r Preparation Dyeing Washing Drying

Grit Separato r 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 Rive r Municipal Water Supply

30,000 GPD Blue Rive r
10,000 GPD Cooling Wate r

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 70,000 GPD + Stormwater Stormwate r Max: 20,000 GPD

Schematic of Water Flow Brown Mills, Inc. Cit y , Count y , StateForm 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 Di scharge 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

. Latitude Longitude Outfall Number ( 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 wa stewater, sanitary wastewater, cooling water, and storm water runoff; (2) The aver age flow contributed by each operation; and (3) The treatment re ceived 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 5B. Attach a line drawing showing the water flow through the facilit y. 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, treatm ent units, and outfalls. If a water balance cannot be determined (e .g., for certain mining activities), provi de a pictorial description of the nature and amount of any sources of water and any collection or trea tment 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 effl uent 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 PAGECONTINUED 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 specifi c 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 aver age for certain pollutants and the source of information. Data for all pollutants in Group A, for all outfalls, must be subm itted 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 pr esent or are limited directly by an effluent limitations g uideline 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 REVERSECONTINUED 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 T able 2D-3 of the instructions which you know or have reason to believe will be discharged from any outfall. For every pollutant you list, brie fly 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 c oncerning your wastewater treatment, incl uding engineering reports or pilot plant stud ies, check the appropriate box below. Report Available No Report
B. Provide the name and location of any ex isting plant(s) which, to the best of your knowledge resembles this production facili ty 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 PAGEEPA I.D. NUMBER ( copy from Item 1 of Form 1 )

VII. Other Information (Optional)

Use the space below to expand upon any of th e above questions or to bring to the attent ion of the reviewer any other informatio n you feel should be considered in establishing permit limi tations for the proposed facility. A ttach additional sheets if necessary.

VIII. CERTIFICATION

I certify under penalty of law that this document and all attach ments were prepared under my direction or supervision in accord ance with a system designed to assure that qualified personnel properly gather and eval uate 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 th e best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false inform ation, including the possibility of fine and imprisonm ent 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 docum ent that allows you to type your information directly into the form, print it, and save the completed form.

Note: This f orm can be viewed and saved only using Adobe Acrobat Reader version 7.0 or higher, or if you have the full Adobe Professional version.

Instru ctions: 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 comp leted in conjunction with EPA Form 3510-1 (Form 1). This short form may be used only by operators of fac ilities 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 produc t, 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 Stat es 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 addr esses 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 require d 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 comp lete 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 appl icable”) 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 pa rameters 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 th e 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 gener al type(s) of wastes to be discharged by placing an “x” in the appropriate box(es). If “other nonprocess wastewat er” 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 report ed. The source of the estimates is also required. Base your determination of whether a pollutant will be pr esent 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 pl ants .....................................1 Estimates from other engineering studies ................2 Data from other similar plants...................................3 Best professional estimates......................................4 Others .......................................... specif y on the form
C. Testing Waivers
To request a waiver from reporting any of these pollutants or parameters, t he 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 t hat 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 Clea n Water Act provides that “Any person who knowingly ma kes any false statement, representation, or certificati on 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 re sponsible 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 qua rter 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 princi pal 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).

Latitude Longitude Outfall 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. Briefl y 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 t he 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 dem and (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 2V. 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 t he above questions or to bring to the attent ion of the reviewer any other informati on you feel should be considered in establis hing permit limitations. Attach additional sheets, if necessary.

VIII. CERTIFICATION I certify under penalty of law that this document and all attach ments were prepared under my direction or supervision in accord ance with a system designed to assure that qualified personnel properly gathe r and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsib le for gathering the information, the information submitted i s to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penal ties for submitting false inf ormation, 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 docum ent that allows you to type your information directly into the form, print it, and save the completed form.

Note: This f orm can be viewed and saved only using Adobe Acrobat Reader version 7.0 or higher, or if you have the full Adobe Professional version.

Instru ctions: 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 wi th 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 i nstructions, searching existing data sources, gathering and maintaining the data needed, and completing and review ing the collection of information. Send comments regarding the burden estimate, any other aspect of this collection of information, or su ggestions for improving this form, including suggestions which may increase or reduce t his burden to: Chief, Information Policy Branch, PM-223, U.S. Environmental Protection Agency, 1200 Pennsy lvania Avenue, NW, Washington, DC 20460, or Director, Office o f Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.



### I. Outfall Location
For each outfall, list the latitude and longit ude of its location to the nearest 15 sec onds 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 author ity to meet any implementation schedule for the construction, upg rading or operation of wastewater

treatment equipment or practices or any other environmental pr ograms which may affect the discharges described in this applicat ion? This includes, but is not limited to, permit conditions, administrative or enforcement orders, en forcement compliance schedule letters, stipulations, court order s, and grant or loan conditions.

2. Affected Outfalls 4. Final Compliance Date 1. Identification of Conditions, Agreements, Etc. number source of discharge 3. Brief Description of Project a. req. b. proj.

B: You may attach additional sheets describing any additional wa ter 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 appl ication 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; p aved areas and buildings within the drainage area of each storm water outfall, each known past or present areas used for outdoor stor age of disposal of significant material s, each existing struct ural control measure to reduce pollutants in storm water runoff, materials loading and access areas, areas where pesticides, herbicides, soil condit ioners 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 bodie s which received storm water discharges from the facility.

EPA Form 3510-2F (1-92) Page 1 of 3 Continue on Page 2Continued 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 signifi cant materials that are currently or in the past three years have been treated, st ored 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 t he 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 t he 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 eit her 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 us ed, the date of any testing, and the onsit e drainage points that were directly observe d during a test.



### VI. Significant Leaks or Spills

Provide existing information regarding the hi story of significant leaks or spills of toxic or hazardous pollutants at the facil ity 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 pr oceeding. Complete one set of tables for each outfall. Annotate the outfall number in t he 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 y our 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 per formed 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 attach ments were prepared under my direction or supervision in accord ance with a system designed to assure that qualified personnel properly gather and evaluate the informati on submitted. Based on my inqui ry of the person or persons w ho manage the system or those persons directly responsible for gathering the info rmation, the information s ubmitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false informati on, including the possibility of fine and imprisonment for knowin g 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 3EPA 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 fo r every pollutant in this table. Complete one table for each o utfall. 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 t hat 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 operati ng under an existing NPDES permit). Complete one table for each outfall. See the instruct ions 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 ReverseContinued from the Front Part C - List each pollutant shown in Tabl e 2F-2, 2F-3, and 2F-4 that you know or hav e reason to believe is present. See the in structions 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 operato rs of facilities which di scharge storm water associ ated with industrial activity or by operators of storm water discharges that EPA is evaluat ing 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 comp lete Form 2F (EPA Form 3510-2F) in conjunction with Form 1 (EPA Form 3510-1).
Operators of discharges of storm wa ter 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, wast e product, or wastewater) must complete and submit Form 2F, Form 1, and Form 2C (EPA Form 3510-2C).
Operators of discharges of stor m water which are combined with nonprocess wastewater (nonprocess wastewater includes noncontact cooling water and s anitary 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 sour ces or new discharges of st orm water associated with indus trial 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 O ffice 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 facilitie s located in States which are approv ed to administer the NPDES permits program, the State environmental agency should be co ntacted for proper permit application forms and instructions.
Information on whether a particular program is admin istered by EPA or by a St ate 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 no t 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 inform ation will be made available to the public upon request.
Any information you submit to EPA which goes beyond that required by this form, Fo rm 1, or Form 2C you may claim as confidential, but claims for in formation 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 not ice to you. Claims of confidentialit y will be handled in accordance with EPA's business confident iality regulations at 40 CFR Part 2.

Definitions All significant terms used in these in structions 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 latit ude 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 po llution 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 wate r runoff, materials loading and access areas, areas where pesticides, herbicides, soil cond itioners and fertilizers are applied;

each of its hazardous waste treatment, storage or dis posal 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 fa cility are injected underground; and
springs, and other surface water bodies which rece ive storm water discharges from the facility;

Item IV-A For each outfall, provide an estimate of the area dr ained by the outfall which is covered by impervious surfaces. For the purpose of this application, impervious surfaces are surfaces wher e 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. In clude an estimate of the total area (including all impervious and pervious areas) draine d 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 expos ure to storm water; method of treatment, storage or disposal of these materials; past and present materi als 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 pesticid es, herbicides, soil conditioners, and fertilizers are applied. Significant materials should be identified by c hemical name, form (e.g., pow der, 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; fertiliz ers; 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 structur es which enclose material handling or storage areas, covering materials, berms, dikes, or diversion ditche s around manufacturing, production, storage or treatment units, retention ponds, etc. Nonstructural controls incl ude 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 outfa lls that should contain storm water di scharges associated with industrial activity have been tested or evaluat ed for the presence of non-storm wa ter discharges which are not covered by an NPDES permit. Tests for such non-storm water di scharges may include smoke tests, fluorometric dye tests, analysis of accurate schematics, as well as other appropriate te sts. 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 Fo rm 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 info rmation regarding the history of signi ficant leaks or spills of toxic or hazardous pollutants at the fac ility 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 gener al 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 addres sed 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 polluta nt if you know or have reason to kn ow that the pollutant is present in the discharge, and either repor t quantitative data for the pollutant or br iefly 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 abs ent from your discharge on your knowledge of your raw materials, material management practices, maint enance 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 report ed analyses should be supervised by a person experienced in performing sampling of industrial wast ewater or storm water discharges. You may contact EPA or your State permitting authority for detailed guidance on sampli ng techniques and for answers to specific questions. Any specific requirements cont ained 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-weight ed 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 samp le 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 resu lting from a storm event that is greater than 0.1 inches and at least 72 hours from the previously m easurable (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 tak en 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 millilit ers collected during the first thirty minutes (or as soon thereafter as practicable) of the discha rge. 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 aliquot s taken in each hour of discharge for the entire event or for the first three hours of the even t, 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 betw een 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, ali quots 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, proce sses, or final products, and changes in storm water treatment. When the Agency promulgates new analytic al 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, incl uding 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 prev ious measurable storm event and the storm event sampled, the minimum or maximum level of precipitat ion 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 s eparate 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 o ne grab sample and one flow-weighted composite

### EPA Form 3510-2F (Rev. 1-92) I - 5 

## sample for a given outfall, complete only the “M aximum Values” columns an d 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 di scharge, you must report them. You must describe your method of testing and data analysis. You also mu st 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 “N umber 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 provid ed 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 hav e two or more substantially identical outfalls, you may request permission from your permitting author ity to sample and analyze only one outfall and submit the results of the analysis for othe r 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 te st 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 po llutants 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 th irty minutes of discharge a nd flow-weighted composite sample. The “Average Values” column is not compulso ry 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 discussi on 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” co lumn 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 re sults, except as provided in the General Instructions.

Part VII-C Part V11-C must be completed by all applicants for a ll outfalls which discharge storm water associated with industrial activity, or that EPA is ev aluating for designation as a significant contributor of pollutants to waters of the United States, or as contribut ing 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 previous ly listed in Part VII-B). If a pollu tant 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 effl uent 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 descr ibe 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 expect ed to be discharged in concentrations of 10 ppb or greater, you must submit quantitative data. For acrolein, acrylonitr ile, 2,4 dinitrophenol, and 2-methyl-4,6 dinitrophenol, you must submit quantitat ive data if any of these four polluta nts 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 s ubmit 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. T here 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 es timated future production (such as a schedule of estimated total production under 30 CFR 795.14(c)) in stead of conducting analyses for the organic toxic pollutants. If your facility is not a c oal mine, and if your gross total ann ual sales for the mo st 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 or ganic 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 di scharge, unless those are the only processes at your facility. For sales data, in situations involving intracorporate transfer of goods and serv ices, 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 (Depart ment 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 presen t. 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 ex empted from the requirement s of section 311 of CWA, which establishes reporting requirement s, civil penalties, and liability for cleanup costs for spills of oil and hazardous substances. A discharge of a particular su bstance 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 treatm ent of the discharge, and if the treat ment is in place. To apply for an exclusion of the discharge of any hazardous substa nce 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 eac h substance which may be discharged.
2. The origin and source of t he 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 nor mal 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 fu rther 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 stor m 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. Provi de the data and duration of the storm event(s) sampled, rainfall measurement s, or estimates of the storm event which generated the sampled runoff and the duration between the storm event sampled and t he end of the previous meas urable (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 hexachlor ophene (HCP); then list TCDD. The Di rector may waive or modify the requirement if you demonstrate that it would be undul y 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 pollutant s 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 certific ation in any application, . . . shall upon conviction, be punished by a fine of not more than $10,000 or by imprisonment for not mo re than 2 years, or by bot h. If a conviction of such person is for a violation committed after a first convic tion of such person under this paragraph, punishment shall be by a fine of not more than $20,000 per day of vi olation, 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, treasu rer, or vice president of the corporation in charge of a principal business function, or any other pers on 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 hav ing gross annual sales or expenditures exceeding $25,000,000 (in second quarter 1980 dollars), if aut hority to sign documents has been assigned or delegated to the manager in accor dance with corporate procedures.

Note: EPA does not require specific a ssignments or delegation of author ity to responsible corporate officers identified in 122. 22(a)(1)(i) The Agency will presume that these respon sible corporate officers have the requisite authority to sign permit applications unless the corporation has notified the Director to the contrary. Corporate pr ocedures governing authority to sign permit applications may provide for assignment or delegation to applicable corporate positi on 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 sectio n, a principal executive of ficer 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 uni t 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 Dichlorobromomethan e 1,1,2,2,-Tet rachloroethane Acrylonitrile 1,1-Dichloroet hane Tetrachloroethylene Benzene 1,2-Dichloroethane Toluene Bromoform 1,1-Dichloroethylene 1,2-Trans-Dichloroethylene Carbon Tetrachloride 1,2-Dichlor opropane 1,1,1-Trichloroethane Chlorobenzene 1.3-Dichloroprop ylene 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-Nitrophe nol 2,4,6-Trichlorophenol 4,6-Dinitro-O-Cresol p-Chloro-M-Cre sol 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-Dichl orobenzene Hexachloroethane Benzo(a)pyrene 1,3-Dichlorobe nzene 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 Ph thalate N-Nitrosodi-N-Propylamine Bis(2-chloroisopropyl)ether 2,4-Di nitrotoluene N-Nitrosodiphenylamine Bis(2-ethylyhexyl)phthalate 2, 6-Dinitrotoluene Phenanthrene 4-Bromophenyl Phenyl Ether Di-N-Octyphthalate Pyrene Butylbenzyl Phthalate 1,2-Diphenylhydrazi ne (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 docum ent that allows you to type your information directly into the form, print it, and save the completed form.

Note: This f orm can be viewed and saved only using Adobe Acrobat Reader version 7.0 or higher, or if you have the full Adobe Professional version.

Instru ctions: 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 applicat ion 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 author ity 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 ap plying 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 applican t. “This facility” and “your facility” refer to the facility f or 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 ______ applicantEPA 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 contai ner 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 dispos al 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, provi de 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 t he sewage sludge meet at your facility?

_______ Class A _______ Class B _______ Neither or unknown

b. Describe, on this form or another sheet of paper, any treatm ent 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 acti ve 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 requirement s, 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 a nother 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 faci lity 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 certifica tion.)

I certify under penalty of law that this document and all attach ments were prepared under my direction or supervision in accord ance 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 resp onsible for gathering the information, the information is, to th e best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalti es for submitting false infor mation, 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 ha ve been directed by the permitting authority to submit a full per mit 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 applican t. “This facility” and “your facility” refer to the facility f or which application information is submitted.



## APPLICATION OVERVIEW — SEWAGE SLUD GE 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 t o 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, Cla ss 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 ot her container for sale or give-away for application to the land , or 3) The sewage sludge from this facility is s ent to another facility for treatment or blending.

4. SECTION D: SURFACE DISPOSAL

Section D must be completed by applicants w ho 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 s hould be directed to the facility or the applicant.

______ facility ______ applicantEPA 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, St ate, and local permits or construction approvals received or appli ed 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 lo cations 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 i dentifies all sewage sludge processes that will be employed durin g the term of the permit, including all processes used for collecting, dewatering, storing, or treating sewage sludge, the destinatio n(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 contra ctor (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 d ata 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 a n 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 attach ments were prepared under my direction or supervision in accord ance with the system designed to assure that qualified personnel properly gat her and evaluate the information submitted. Based on my inq uiry 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 signi ficant penalties for submitting false information, including the possibility of fi ne and imprisonment for knowing violations.

Name and official title _____________________________________________________________________________

Signature ___________________________________________ Date signed _______________________

Telephone number _____________________________________________________________________________

Upon request of the permitting authority, you must submit any ot her information necessary to assess sewage sludge use or dispos al practices at your facility or identify appr opriate 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 generate d at your facility: _______________________ dry metric tons

B.2. Amount Received from Off Site. If your facility receives sewage sludge from another fa cility 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 treatm ent processes known to occur at the off-site facility, includ ing blending activities and treatment to reduce pathogens or vector attraction characteristics.

________________________________________________________________________________________________

________________________________________________________________________________________________

B.3. Treatment Provided At Your Facility.

a. Which class of pathogen reduc tion 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 treatm ent 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 unknownEPA 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 othe r sewage sludge treatment or blendi ng activities not identified in (a) - (d) above:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Complete Section B.4 if sewage sludge from your facility meet s the ceiling concentrations in Table 1 of 40 CFR 503.13, the poll utant 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 Vecto r 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 secti on placed in bags or other containers for sale or give-away for application to the lan d?

_______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 plac ed in a bag or other container at your facility for sale or gi ve-away for application to the land: _________________________ dry metric tons

b. Attach, with this application, a copy of all labels or notic es 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 pr ovided 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 provi de 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 i n sewage sludge:

_________________________________________________________________________________________________

_________________________________________________________________________________________________ f. Does the receiving facility pr ovide additional treatment to reduce vector a ttraction 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 ra te 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 pr ocesses used at the receiving facility to reduce vector attra ction properties of sewage sludge.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

g. Does the receiving facility provide an y additional treatment or bl ending activities not identif ied 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) ab ove:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

h. If you answered yes to (e), (f), or (g), attach a copy of any information you provide the re ceiving 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 app lication to the land? ______ Yes ______ No

If yes, provide a copy of all labels or notices t hat 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 tonsEPA 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 applicat ion plan with application (see instructions).

c. Are any land application sites located in States other than th e 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 lan d 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 facilit y 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 si te 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 inciner ators 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 ______ N o If no, complete B.9.c through B.9.f for each sewage sludge inciner ator that you do not own or operate. If you send sewage slu dge to more than one such sewage sludge incinerator, a ttach additional pages as necessary.

c. Incinerator name or number: ___________________________________________________________________

d. Contact person: ___________________________________________________________________

Title: ___________________________________________________________________

Telephone number: ___________________________________________________________________

Contact is: _________ Incinerator owner _________ Incinerator operatorEPA 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 fi red 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 mu nicipal solid waste landfill, attach additi onal 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 facilit y 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 disposa l 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 _______ NoEPA 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 re duction 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 w hen 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 a ttraction 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 trea tment processes used at the land application site to reduce vecto r 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 pollutan t 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 wher e the bulk sewage sludge subject to CPLRs will be applied, to a scertain 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 t han yours that is sending, or has sent, bulk sewage sludge to CP LRs 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 sit e location.

d. Total dry metric tons of sewage sludge placed on the active sewage sludge unit per 365-day period: __________________ dry me tric tons

e. Total dry metric tons of sewage sludge placed on the active sewage sludge unit over the life of the unit: _______________ dr y 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 closur e 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 fr om 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 reducti on 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 treatm ent 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 ra te 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 at traction properties of sewage sludge

_____________________________________________________________________________________________

_____________________________________________________________________________________________

h. Describe, on this form or another sheet of paper, any othe r sewage sludge treatment activities performed by the other facili ty 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 th is active sewage sludge unit?

______ Option 9 (Injection below and surface)
______ Option 10 (Incorporation into soil within 6 hours) ______ Option 11 (Covering acti ve 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 treatm ent processes used at the active sewage sludge unit to reduce ve ctor attraction properties of sewage sludge:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

D.4. Ground-Water Monitoring.

a. Is ground-water monitoring currently c onducted at this active sewage sludge unit, or are ground-water monitoring data otherw ise available for this active sewage sludge unit? ______ Yes ______ No

If yes, provide a copy of available ground-water monitoring dat a. Also, provide a written description of the well locations, th e 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 fo r 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-wate r scientist that the aquifer below the active sewage sludge un it 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 t he 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 sew age 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 fir ed in the sewage sludge incinerator: _____________ dry metric tons

E.3. Beryllium NESHAP. a. Is the sewage sludge fired in this incinerator “beryllium-c ontaining waste,” as defined in 40 CFR Part 61.31? ______ Yes ______ No

Submit, with this application, information, test data, and de scription of measures taken that demonstrate whether the sewage s ludge 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 t he NESHAP emission rate limit for beryllium has been and will cont inue 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 incinera tor has met, and will continue to meet, the mercury NESHAP emission rate limit.

Copies of mercury emission rate tests for the tw o 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 document ation of ongoing incinerator operating parameters indicating that the inci nerator has met, and will continue to meet the mercury NESHAP emission
rate limit.

E.5. Dispersion Factor. a. Dispersion factor, in micrograms/c ubic 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 s upporting documentation (including te sting dates) with this applica tion.

E.7. Risk Specific Concentration for Chromium. a. Risk specific concentration (RSC) used for chro mium, 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 (s ite-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 chromi um concentration to total chromium c oncentration in stack exit gas: _____________

Submit results of incinerator stack tests for hexavalent and to tal chromium concentrations, incl uding date(s) of test, with th is 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: ______ Ac tual 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, inform ation documenting the performance test operat ing parameters for the air pollution contr ol 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 ai r 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 U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY W ASHINGTON , DC 20460 N OTICE OF I NTENT (NOI) FOR S TORMWATER D ISCHARGES A SSOCIATED WITH INDUSTRIAL ACTIVITY UNDER THE NPDES M ULTI -S ECTOR G ENERAL P ERMIT Form Approved. OMB No. 2040-0086

Submission of this completed Notice of In tent (NOI) constitutes notice that the operator identified in Section B of this form r equests authorization to discharge pollutants to waters of the United States from the facility or site identif ied in Section C under EPA’s NPDES Stormwater Multi-Sector Gene ral Permit (MSGP) for industrial stormwater. Submission of this NOI constitutes your notice to EP A 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 eligibilit y 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 Identific ation 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 dischar ging stormwater prior to October 30, 2005? YES NO

b.2 If no to C.2.b.1, did your fa cility 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 pa rt 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.)

If you answered yes to question D.2.b, th en answer the following three questions: a. What is the name(s) of your receiving water(s) 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 antid egradation policy as a Tier 2 (or Tier 2.5) water (water quality exceeds levels necessary to suppor t propagation of fish, shellfish, and wildlife and recreation in an d on the water)? YES NO b. Has the receiving water(s) been designated by the state or tr ibal authority under its antidegradation policy as a Tier 3 wat er (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 Aff ected 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 manu facturing 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 deici ng/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 produc ts 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 indust rial activity, including co-locat ed industrial activity, for whi ch 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 inac tive 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 unstaff ed _______________________________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-desi gnated 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 per mit? 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 pollut ants 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 limit ation guideline or cause or contribute to an exceedance of a State or Tribal wa ter 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. Docu mentation should address species and habitat listed in F.2.a a nd 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 un der this permit?

A B C D

H. Certifier Name and Title
I certify under penalty of law that I meet the eligibility conditi ons 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 t hat qualified personnel properly gather and evaluate the informatio n submitted. Based on my inquiry of the person or persons who manage the system, or those persons dire ctly responsible for gathering the information, I certify tha t the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I cert ify that I am aware that ther e are significant penalties for su bmitting false information, including the possibility of fines and impris onment 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)

If you answered yes to question D.2.b, th en answer the following three questions:

a. What is the name(s) of your receiving water(s) 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 NOEPA 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 Wate r Act (CWA) and regulations at 40 CFR Part 122, stormwater discharges associated with industrial acti vity are prohibited to waters of the United States unless aut horized under a National Pollutant Discharge Elimination System (NPDES) permit. You can obtain co verage 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 stormwat er pollution prevention pl an (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 stor mwater permit, contact your EPA or State NPDES stormwater permit pr ogram. Contacts are listed at www.epa.gov/npdes/stormwatercontacts

.

One NOI must be submitted for each facili ty 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 SW PPP, install and im plement 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 y ou can comply with the implementation requirements of the permit.

Where to File the NOI Form

EPA encourages you to complete the NOI fo rm electronically via the Internet. EPA’s Electronic Notice of Intent System (e NOI) 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 Pr ocessing 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 No tice 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 subm itted 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 elec tronically 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 exam ple, 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, stat e or territorial NPDES st ormwater 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 descr ibed in this application. An operator of a facility is a legal entity that c ontrols the operation of the facility. 2. Provide the Employer I dentification Number (EIN from the Internal Revenue

Service (IRS)), commonly referred to as y our taxpayer ID num ber. 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. Correspond ence will be sent to this address. Section C. Facility Information 1. Enter the facility’s offici al or legal name. Unless the name of your facility has changed, please use the same name pr ovided 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 st ormwater 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 c onfirmation letter or email from EPA’s Stormwater Notice Processing Cent er. You can find the tracking number assigned to your previous NO I on EPA’s NOI Search website ( www.epa.gov/npdes /noisearch ). 2b1.If your facility was not previously covered by an NPD ES 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 bef ore 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 Date 1 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 y ou 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 t he 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 waiti ng period before you are authorized to discharge. If you select “no” to th is 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 di scharge. 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 addr ess, 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 latit ude and longitude though Global Positioning System (GPS) receivers, U.S. G eological Survey (USGS) quadrangle or topographic maps, and EPA’s web-based si ting-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 fa cility, including pipes, di tches, 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. Scal e 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 facili ty” - Federal facilities include any buildings, installations, structures, land, public works, equipment, aircraft, vessels, and other vehicl es and property, owned or leased by the federal government. 6. Indicate whether the facility is locat ed in Indian Country, and, if so, provide the name of the reservation, if applicable.

Section D. Discharge Information 1. Indicate whether stormw ater 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 draina ge systems, municipal streets, catch basins, storm drains, curbs and gutte rs, ditches and man-made channels, owned or operated by a state, city, to wn, borough, county, parish, district, association or other public body, used to collect or convey stormwater. If you check “Yes” then identify the name of t he MS4 operator on the line provided. If you are uncertain of the MS4 operator, c ontact 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 permi t but may be subject to other CWA requirements (contact the combined sewe r operator for more information). 2. Enter information regarding your disc harge. 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 wi ll discharge. Also pr ovide in parentheses the name of the impaired water (and segm ent, if applicable) into which your stormwater is discharged. If you identifi ed more than on receiving water for your facility, indicate the firs t receiving water and comple te question 2b and 2.b.1-3 (if applicable), before entering the next rece iving water. The EPA’s Water Locator Tool can help you identif y 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 ma y or may not be located adjacent to your facility. Your stormwater may disc harge 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 waterb ody your discharge will reach. Similarly, a discharge into a ditch that feeds Spri ng 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 “im paired” 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 caus ing 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 ident ified 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 identif ied 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 ans wer this question; otherwise you are considered an existing discharger and ma y skip this question. State water quality agencies are responsible for setting water quality standards for waters within the state’s boundarie s. Check EPA’s website ( www.epa.gov/npdes/msgp ) to determine if the water(s) that you di scharge 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 disc harge 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 Guideli nes and Sector-Specific Requirements 4.a-b. Depending on your industrial activities, your facility may be subject to effluent limitation guidelines which include addi tional 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 Transporta tion), indicate whether you anticipate that the entire airport facility will use more than 100,000 gallons of glycol-based deicing/anti-icing chemical s and/or 100 tons or more of urea on an average annual basis. If so, additional effluent lim its 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 descri bes the primary industrial activities performed by your facility under whic h you are required to obtain permit coverage. Your primary industrial acti vity includes any activities performed onsite which are (1) identified by the facili ty’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 ac tivities 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 faci lity will be inactive and uns taffed 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 expec t 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 i mmediate access to individual s with that knowledge. This person does not have to be the faci lity operator, but should have intimate knowledge of stormwater management activities at the facility. 2. If you are making your Stormwater Po llution Prevention Plan publicly available on a website provide the appropriate Inter net URL address. (Please note that by posting your SWPPP on the web, you ma y qualify for a shor tened 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) li sted 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 f ederally-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 st ormwater 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 y ou are considered an ex isting discharger and must answer all the questions in F.2.c.1- -5; otherwise you ar e considered a new discharger and may skip the questions under F.2.c. If you are an existing discharger who was previ ously 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 charac terizing 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 Tr ibal water quality requirement(s). 2.d. Attach your supporting rationale for y our determination of the applicability of Criterion E for your facilit y (applies to both new and ex isting 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 tra cking 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 airpor t has already certified under Appendix E, and that certification addresses any pot ential impacts from the individual airlines, then the airlines may refer ence the airport’s per mit 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 fo r 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 un signed or undated NOI form will prevent the granting of permit cover age.) Federal statutes provide for severe penalties for submitting false information on this applicati on form. Federal regulat ions require this application to be signed as follows: For a corporation: by a responsible corporate officer, which means: (i) president, secretary, treas urer, or vice-president of t he corporation in charge of a principal business function, or any other person who performs similar policy or decision making functions fo r the corporation, or (ii) the manager of one or more manufactu ring, production, or operating facilities, provided the manager is authorized to make management decisions which govern the operation of t he regulated facility including having t he explicit or implicit duty of making major capital investment recomm endations, and initiating and directing other comprehensive measures to assure l ong 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 requi rements; 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 ranki ng elected official.

If the NOI was prepared by someone other than the certifier (for example, if the NOI was prepared by the facility SWPPP cont act 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 certificat ion is estimated to average 3.7 hours per certification, including time for review ing 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, ma intain, retain, or disclose to provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acqui re, install, and utilize tec hnology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and pr oviding information; adjust the existing ways to comply with any previously applic able instructions and requirements; train personnel to be able to respond to a collecti on of information; search data sources; complete and review the collection of info rmation; 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 inform ation unless it displays a currently valid OMB control number. Send comments regar ding the burden estimate, any other aspect of the collection of information, or suggestions for improving this form, including any suggestions which may incr ease or reduce this burden to: Director, Office of Environmental Information Serv ices, Collection Serv ices Division (2823), USEPA, 1200 Pennsylvania Avenue, NW, Wa shington, 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 Pr evious Form 2040-0086 (Please See Instructions Before Completing This Form)

NPDES FORM 3510-7 U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY W ASHINGTON , DC 20460 N OTICE OF T ERMINATION (NOT) OF C OVERAGE UNDER A NPDES G ENERAL P ERMIT
FOR S TORMWATER D ISCHARGES A SSOCIATED WITH I NDUSTRIAL A CTIVITY Form Approved. OMB No. 2040-0086

Submission of this Notice of Termination (NOT) constitutes noti ce that the party identified in Section B of this form is no lon ger authorized to discharge stormwater associated with industrial activity under the NPDES program for the facility identifi ed in Section C of this form. All necessar y 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 necessar y 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 Identific ation 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 d ischarge 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 Te rmination for Stormwater Discharges Associ ated with INDUSTRIAL ACTIVITY under the M ulti-Sector General Permit (MSGP) Who May File Notice of Termination (NOT) Form

Permittees currently covered by EPA’s NP DES Stormwater Mult i-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 facili ty and there are not or no longer will be

discharges of stormwater a ssociated 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 alter native 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 Inte rnet. 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 upper case 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 complet ed 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 St ormwater Notice Processing Center at (866) 352-7755.

Section A. Permit Information

1. Enter the NPDES tracki ng number assigned by EPA’s Stor mwater 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 operat or of the facility is the legal entity which controls the facility’s operation, rather than the pl ant 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 operat or. 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 l egal name and complete address, including city, county or similar government subdi vision, 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 pr inted 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 offi cer, which means: (i) president, secretary, treasurer, or vice-president of the corporat ion in charge of the principal business function, or any other person who performs similar poli cy or decision making functions, or (ii) the manager of one or mo re manufacturing, production, or operating facilities employing more than 250 pers ons 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 elec ted official.

Paperwork Reduction Act Notice

Public reporting burden for this applicati on is estimated to average 0.5 hours per application, including time for reviewing inst ructions, 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 reduc e this burden to: Director, Office of Environmental Inform ation Services, Collection Serv ices 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, opera tors are to use the Notice of Intent Form contained in this Appendix to obtain permit coverage.

Small and Large Construction Activities E-1N (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 identifi ed in Section II of this form requests auth orization to discharge pursuant to the NPDES Construction General Permit (CGP) permit number identifie d in Section I of this form. Submissio n of this NOI also constitutes notice that the party identified in Section II of this form meet s the eligibility requi rements of the CGP for the project identified in Section III of this form. Permit coverage is requir ed prior to commencement of construction activity until you ar e 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):

.

### 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 y ou satisfied your ESA eligibility obligations?

A B C D E F

If you select criterion F, provide permit tracking num ber of operator under which you are certifying eligibility:



### VII. Certification Information
I certify under penalty of law that this document and all attachm ents were prepared under my direction or supervision in accord ance with a system designed to assure that qualifi ed personnel properly gathered and evaluated the information submitted. Based on my inqui ry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information s ubmitted is, to the best of my knowledge and belief, true, accurate, and comp lete. I am aware that there are significant penalties for s ubmitting false information, including the possibility of fi ne 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:

### 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 dischar ge is covered under a National Pollutant Discharge Elimination System (NPDES) Permit. Operator(s) of construction site s 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 st ate 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 ent ity that operates the project described in this application. An operator of a project is a legal entity that controls at least a por tion 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, indica te the general lo cation of the site (e.g., Intersection of State Highways 61 and 34). Complete site info rmation 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 l ongitude. 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. Indi cate to the nearest quar ter 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 ma y 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 dischar ge 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

### 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 ot her 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 t he 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 th is 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, treasu rer, or vice-president of the corporation in charge of a prin cipal 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 operat ion 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, f ederal, 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 Ad ministrator 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 existi ng 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 fo r 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 3510-11 (09-08) Page 1 of 4 NPDES FORM 3510-11 U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY W ASHINGTON
, DC 20460 N O E XPOSURE CERTIFICATION FOR EXCLUSION FROM NPDES STORMWATER
PERMITTING Form Approved OMB No. 2040-0211

Submission of this No Exposure Certificat ion constitutes notice that the entity iden tified in Section A does not require permit authorization for its stormwater discharges associated with industrial activity in th e State identified in Section B under EPA’s Stormwater Multi Sec tor General Permit due to the existence of a condition of no exposure.
A condition of no exposure exists at an i ndustrial facility when all industrial materi als and activities are protected by a sto rm resistant shelter to prevent exposure to rain, snow, snowmelt, and/or runoff. Industria l materials or activities include, but are not limited to, ma terial handling equipment or activities, industrial machinery, raw materials, intermediate products, by-produc ts, final products, or waste products. Mate rial handling activities include the storage, loading and unloading, transportation, or convey ance of any raw material, in termediate product, final prod uct or waste product. A storm resistant shelter is not required for the following industrial ma terials and activities: – drums, barrels, tanks, and similar containers that are tightly sealed, provided those contai ners 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 m obilized in stormwater discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qu alifying for the no exposure excl usion. In addition, the exclu sion from NPDES permitting is available on a facility-wide bas is only, not for individual outfalls. If an y industrial activities or materials a re 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 Sect ion A is certifying that a condition of no exp osure exists at its facility or site, and is obligated to comply with th e 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, per vious area in order to qualify for the no exposure exclusion? YES NO

b. If yes, please indicate approximately how much area was pav ed or roofed over. Completing th is question does not disqualify y ou for the no

exposure exclusion. However, your permitting authority may use this information in c onsidering whether stormwater discharges fr om your site are likely to have an adverse impact on water quality, in wh ich 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 precipitati on, 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 re siduals 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 fr om past industrial activity

4. Material handling equipment (exc ept adequately maintained vehicles)

5. Materials or products during l oading/unloading or trans porting activities

6. Materials or products stored outdoor s (except final products intended fo r outside use [e.g., new cars] where

exposure to stormwater does not resu lt in the discharge of pollutants)

7. Materials contained in open, deteriorated or leaking st orage 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 fr om 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 exp osure” and obtaining an exclusion from NPDES stormwater permitting. I certify under penalty of law that there are no discharges of st ormwater contaminated by exposur e to industrial activities or materials from the industrial facility or site identified in this doc ument (except as allowed under 40 CFR 122.26(g)(2)). I understand that I am obligated to submit a no exposure certific ation form once every five years to the NPDES permitting autho rity and, if requested, to the operator of the local municipal separate storm sewer system (MS4) into which the facility discharges (where a pplicable). I understand that I must allow the NPDES permitting authority, or MS 4 operator where the discharge is into the local MS4, to perf orm inspections to confirm the condition of no exposure and to make such insp ection reports publicly avail able upon request. I understand that I must obtain coverage under an NPDES permit prior to any point sour ce 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 supervi sion in accordance with a system designed to assure that qualified personnel proper ly gathered and evaluated the information submitted. Based on m y inquiry of the person or persons who manage the system, or those persons direct ly responsible for gathering the information, the information s ubmitted is to the best of my knowledge and belief true, accurate and complete. I am aware that there are signi ficant 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 stormwat er 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 constr uction 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 descri bed 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 stor mwater, 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 condit ion 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 per son, firm, public organization, or any other entity that operates the fa cility or site described in this certification. The nam e 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 operati on, rather than the plant or site manager.

2. Provide the telephone numbe r of the facility operator.

3. Provide the email addr ess 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 fac ility is located on Indian Lands.

4. Indicate whether the indus trial 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 longitud e of the approximate center of the facility or site in degr ees/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 t he decimal point are the degrees: 45°.

b) To obtain minutes, multiply t he 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. Sinc e 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 demonstrat ed in the following example.

Example : Convert 54,450 ft 2 

### to acres

Divide 54,450 ft 2 

### by 43,450 square feet per acre: 54, 450 ft 2 

### ) 43,560 ft 2 

### /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 elim inate 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, treas urer, 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; a nd where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;

For a partnership or sole propr ietorship: 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 cert ification is estimated to average 1.0 hour per certification, includi ng 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 collecti on 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, Washin gton, D.C. 20460. Include the OMB control number of this form on any correspondence. Do not send the completed No Exposure Cert ification 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 co nstitutes notice that the par ty identified in Section II of this form is no longer a uthorized to discharge stormwater associated with constr uction activity under the NPDES program from the site identified in Section III of t his form. All necessary information must be included on this form. Re fer 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 achiev ed on all portions of the site for which you are responsible.

Another operator has assumed control, according to Appendix G, Se ction 11.C of the CGP, over all areas of the site that have n ot been

finally stabilized.

Coverage under an alternative NPDES permit has been obtained.

For residential construction only, tem porary stabilization has been completed and th e residence has been transferred to the ho meowner.


### 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 attachm ents were prepared under my direction or supervision in accord ance with a system designed to assure that qualifi ed personnel properly gathered and evaluated t he information submitted. Based on my inqui ry of the person or persons who manage the system, or those persons direct ly responsible for gathering the information, the information s ubmitted is, to the best of my knowledge and belief, true, accurate, and complete . I am aware that there are si gnificant penalties for submi tting false information, including the possibility of fi ne 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 co vered 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 st abilization 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 construc tion only, temporary stabilization has been completed and the residence has been transferred to the homeowner.

“Final stabilization” means that all so il 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 Gener al Permit for further guidance where background native vegetation covers less than 100 percent of the ground, in arid or semi-arid ar eas, for individual lots in residential construction, and for cons truction projects on l and used for agricultural purposes.

Completing the Form Type or print, using uppercase letters, in the appropriate areas only. Please place each character betw een 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 (8 66) 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 nu mber identified in Section I. The operator of the project is the legal ent ity 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 responsibl e corporate officer means: (i) a president, secretary, treasurer, or vice-president of the corporation in charge of a principal business f unction, or any other person who performs similar policy-or decis ion-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 complianc e 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 ranki ng elected official. For purposes of this Part, a principal executive offi cer of a federal agency includes (i) the chief executive officer of the a gency, 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 app lication 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 fo rm 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

## This page intentionally left blank.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 C o n t a c t e d 

# G Yes 

# G No



### Section C: Areas Evaluated During Inspection (Check only those areas evaluated)

Permit Self-Monitoring Program Pretreatment MS4 Compliance Schedules Pollution Prevention Records/Reports 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

# S i n g l e E v e n t V i o l a t i o n T a b l e

­ C o d e s a n d D e s c r i p t i o n s *

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



## 1E0012 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

## This page intentionally left blank.

## 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 i dentified in Section I of this form, are certifying that const ruction activity at the project site identified in Section II, will take place during a peri od when the rainfall eros ivity factor is le ss 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 construc tion activity, are waived. Based on your certification, a waiver is granted for the period begi nning on the date this Low Erosivity Waiver Form is mailed to EPA (i.e., postmark date), or the proj ect start date specified in Part III of this form, whichever shall occur last, and ending on the projec t 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 fo rmats 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 associ ated with oil and gas exploration, drilling, operations, and pipeli nes

(includes SIC Groups 13 and 46, and SI C codes 492 and 5171)? Yes No

• Is the project located in the State of Oklahoma and associ ated 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 F actor 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 t han five acres and shall take place during a period when the rainfall erosivity fa ctor is less than five, (2) final stabilization will be comp leted 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 properl y 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, th e information submitted is, to the best of my knowledge and belief, true, accurate , and complete. I am aware that there are significant penalties for s ubmitting false information, including the possibility of fine a nd imprisonment for knowing violations. Further, if interim non-veget ative measures are used to es tablish the end of the construct ion period for the purposes of obtaining this waiver, I commit to per iodically inspect and properly maintain the area until the cri teria 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 c onstruction 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 quad rangle 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 environmenta l 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 requ ired 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 Univer sal 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 greate r 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 Certific ation 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 sim ilar 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, Informat ion 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 /200 6 ) 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 inf ormation 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 address this 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 "

.


### ( S F

- 299, 

### page 

## 3 ) NOTE

(Items

ranges

### SUPPLEMENTAL

CHECK APPROPRIATE NOTE: 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.

1 II - PUBLIC 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 furnishe d 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 (D OI) 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 cong ressional office when you request the a ssistance of the Member of Congress in writing. EFFECT OF NOT PROVIDING THE INFORMATION: Disclosi ng 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 info rmation 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.

__________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________ 

## (SF – 299, page 5)