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

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

OMB Number 2040-0086

FORM

2A

NPDES

NPDES FORM 2A APPLICATION OVERVIEW

APPLICATION OVERVIEW

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

and a "Supplemental Application Information" packet. The Basic Application Information packet is divided

into two parts. All applicants must complete Parts A and C. Applicants with a design flow greater than or

equal to 0.1 mgd must also complete Part B. Some applicants must also complete the Supplemental

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

BASIC APPLICATION INFORMATION:

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

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

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

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

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

SUPPLEMENTAL APPLICATION INFORMATION:

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

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

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

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

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

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

Testing Data):

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

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

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

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

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

and RCRA/CERCLA Wastes). SIUs are defined as:

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

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

2. Any other industrial user that:

a. Discharges an average of 25,000 gallons per day or more of process wastewater to the treatment works (with certain

exclusions); or

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

capacity of the treatment plant; or

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

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

Systems).

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

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

OMB Number 2040-0086

BASIC APPLICATION INFORMATION

PART A. BASIC APPLICATION INFORMATION FOR ALL APPLICANTS:

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

A.1. Facility Information.

Facility name

Mailing Address

Contact person

Title

Telephone number

Facility Address

(not P.O. Box)

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

Applicant name

Mailing Address

Contact person

Title

Telephone number

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

owner operator

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

facility applicant

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

(include state-issued permits).

NPDES PSD

UIC Other

RCRA Other

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

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

Name Population Served Type of Collection System Ownership

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

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

OMB Number 2040-0086

A.5. Indian Country.

a. Is the treatment works located in Indian Country?

Yes No

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

through) Indian Country?

Yes No

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

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

month of "this year" occurring no more than three months prior to this application submittal.

a. Design flow rate _______________ mgd

Two Years Ago Last Year This Year

b. Annual average daily flow rate mgd

c. Maximum daily flow rate mgd

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

contribution (by miles) of each.

Separate sanitary sewer %

Combined storm and sanitary sewer %

A.8. Discharges and Other Disposal Methods.

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

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

i. Discharges of treated effluent

ii. Discharges of untreated or partially treated effluent

iii. Combined sewer overflow points

iv. Constructed emergency overflows (prior to the headworks)

v. Other

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

that do not have outlets for discharge to waters of the U.S.? Yes No

If yes, provide the following for each surface impoundment:

Location:

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

Is discharge continuous or intermittent?

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

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

Location:

Number of acres:

Annual average daily volume applied to site: Mgd

Is land application continuous or intermittent?

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

treatment works? Yes No
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 4 of 21

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

OMB Number 2040-0086

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

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

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

Transporter name:

Mailing Address:

Contact person:

Title:

Telephone number:

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

Name:

Mailing Address:

Contact person:

Title:

Telephone number:

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

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

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

A.8.a through A.8.d above (e.g., underground percolation, well injection)? Yes No

If yes, provide the following for each disposal method:

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

Annual daily volume disposed of by this method:

Is disposal through this method continuous or intermittent?
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 5 of 21

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

OMB Number 2040-0086

WASTEWATER DISCHARGES:

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

effluent is discharged. Do not include information on combined sewer overflows in this section. If you answered "no" to question A.8.a, go to

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

A.9. Description of Outfall.

a. Outfall number

b. Location

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

(County) (State)

(Latitude) (Longitude)

c. Distance from shore (if applicable) ft.

d. Depth below surface (if applicable) ft.

e. Average daily flow rate mgd

f. Does this outfall have either an intermittent or a periodic

discharge?

Yes No (go to A.9.g.)

If yes, provide the following information:

Number of times per year discharge occurs:

Average duration of each discharge:

Average flow per discharge: mgd

Months in which discharge occurs:

g. Is outfall equipped with a diffuser? Yes No

A.10. Description of Receiving Waters.

a. Name of receiving water

b. Name of watershed (if known)

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

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

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

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

acute cfs chronic ______________ cfs

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

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

OMB Number 2040-0086

A.11. Description of Treatment.

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

Primary Secondary

Advanced Other. Describe:

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

Design BOD5 removal or Design CBOD5 removal %

Design SS removal %

Design P removal %

Design N removal %

Other %

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

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

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

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

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

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

collected through analysis conducted using 40 CFR Part 136 methods. In addition, this data must comply with QA/QC requirements of

40 CFR Part 136 and other appropriate QA/QC requirements for standard methods for analytes not addressed by 40 CFR Part 136. At a

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

Outfall number:

PARAMETER MAXIMUM DAILY VALUE AVERAGE DAILY VALUE

Value Units Value Units Number of Samples

pH (Minimum) s.u.

pH (Maximum) s.u.

Flow Rate

Temperature (Winter)

Temperature (Summer)

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

POLLUTANT MAXIMUM DAILY

DISCHARGE

AVERAGE DAILY DISCHARGE ANALYTICAL

METHOD

ML / MDL

Conc. Units Conc. Units Number of

Samples

CONVENTIONAL AND NONCONVENTIONAL COMPOUNDS.

BIOCHEMICAL OXYGEN BOD-5

DEMAND (Report one) CBOD-5

FECAL COLIFORM

TOTAL SUSPENDED SOLIDS (TSS)

END OF PART A.

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

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

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

OMB Number 2040-0086

BASIC APPLICATION INFORMATION

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

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

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

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

 ___________________gpd

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

______________________________________________________________________________________________________

______________________________________________________________________________________________________

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

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

area.)

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

b. The major pipes or other structures through which wastewater enters the treatment works and the pipes or other structures through which

treated wastewater is discharged from the treatment plant. Include outfalls from bypass piping, if applicable.

c. Each well where wastewater from the treatment plant is injected underground.

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

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

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

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

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

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

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

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

treatment units. Include a brief narrative description of the diagram.

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

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

contractor? ____Yes ____No

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

if necessary).

Name:

Mailing Address:

Telephone Number:

Responsibilities of Contractor:

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

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

treatment works has several different implementation schedules or is planning several improvements, submit separate responses to question B.5 for

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

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

 __________________________________________________________________________

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

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

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

OMB Number 2040-0086

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

____________________________________________________________________________________

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

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

Indicate dates as accurately as possible.

Schedule Actual Completion

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

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

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

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

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

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

Describe briefly: ________________________________________________________

 ________________________________________________________

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

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

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

this section. All information reported must be based on data collected through analysis conducted using 40 CFR Part 136 methods. In addition, this

data must comply with QA/QC requirements of 40 CFR Part 136 and other appropriate QA/QC requirements for standard methods for analytes not

addressed by 40 CFR Part 136. At a minimum, effluent testing data must be based on at least three pollutant scans and must be no more than four

and one-half years old.

Outfall Number:________________

POLLUTANT MAXIMUM DAILY

DISCHARGE

AVERAGE DAILY DISCHARGE

Conc. Units Conc. Units Number of

Samples

ANALYTICAL

METHOD

ML / MDL

CONVENTIONAL AND NONCONVENTIONAL COMPOUNDS.

AMMONIA (as N)

CHLORINE (TOTAL

RESIDUAL, TRC)

DISSOLVED OXYGEN

TOTAL KJELDAHL

NITROGEN (TKN)

NITRATE PLUS NITRITE

NITROGEN

OIL and GREASE

PHOSPHORUS (Total)

TOTAL DISSOLVED

SOLIDS (TDS)

OTHER

END OF PART B.

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

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

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

OMB Number 2040-0086

BASIC APPLICATION INFORMATION

PART C. CERTIFICATION

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

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

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

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

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

_____ Basic Application Information packet Supplemental Application Information packet:

 ______ Part D (Expanded Effluent Testing Data)

 ______ Part E (Toxicity Testing: Biomonitoring Data)

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

 ______ Part G (Combined Sewer Systems)

ALL APPLICANTS MUST COMPLETE THE FOLLOWING CERTIFICATION.

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

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

system or those persons directly responsible for gathering the information, the information is, to the best of my knowledge and belief, true, accurate, and

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

violations.

Name and official title _____________________________________________________________________________

Signature ____________________________________________________________________________

Telephone number _____________________________________________________________________________

Date signed ______________________________________________________________________________

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

or identify appropriate permitting requirements.

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

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

OMB Number 2040-0086

SUPPLEMENTAL APPLICATION INFORMATION

PART D. EXPANDED EFFLUENT TESTING DATA

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

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

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

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

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

collected through analyses conducted using 40 CFR Part 136 methods. In addition, these data must comply with QA/QC requirements of 40 CFR Part 136

and other appropriate QA/QC requirements for standard methods for analytes not addressed by 40 CFR Part 136. Indicate in the blank rows provided

below any data you may have on pollutants not specifically listed in this form. At a minimum, effluent testing data must be based on at least three pollutant

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

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

POLLUTANT MAXIMUM DAILY

DISCHARGE

AVERAGE DAILY DISCHARGE

Conc. Units Mass Units Conc. Units Mass Units Number

of

Samples

ANALYTICAL

METHOD

ML/ MDL

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

ANTIMONY

ARSENIC

BERYLLIUM

CADMIUM

CHROMIUM

COPPER

LEAD

MERCURY

NICKEL

SELENIUM

SILVER

THALLIUM

ZINC

CYANIDE

TOTAL PHENOLIC COMPOUNDS

HARDNESS (AS CaCO3)

Use this space (or a separate sheet) to provide information on other metals requested by the permit writer.
EPA Form 3510-2A (Rev. 1-99). Replaces EPA forms 7550-6 & 7550-22. Page 11 of 21

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

OMB Number 2040-0086

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

POLLUTANT MAXIMUM DAILY

DISCHARGE

AVERAGE DAILY DISCHARGE

Conc. Units Mass Units Conc. Units Mass Units Number

of

Samples

ANALYTICAL

METHOD

ML/ MDL

VOLATILE ORGANIC COMPOUNDS.

ACROLEIN

ACRYLONITRILE

BENZENE

BROMOFORM

CARBON TETRACHLORIDE

CLOROBENZENE

CHLORODIBROMO-METHANE

CHLOROETHANE

2-CHLORO-ETHYLVINYL

ETHER

CHLOROFORM

DICHLOROBROMO-METHANE

1,1-DICHLOROETHANE

1,2-DICHLOROETHANE

TRANS-1,2-DICHLORO-ETHYLENE

1,1-DICHLOROETHYLENE

1,2-DICHLOROPROPANE

1,3-DICHLORO-PROPYLENE

ETHYLBENZENE

METHYL BROMIDE

METHYL CHLORIDE

METHYLENE CHLORIDE

1,1,2,2-TETRACHLORO-ETHANE

TETRACHLORO-ETHYLENE

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

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

OMB Number 2040-0086

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

POLLUTANT MAXIMUM DAILY

DISCHARGE

AVERAGE DAILY DISCHARGE

Conc. Units Mass Units Conc. Units Mass Units Number

of

Samples

ANALYTICAL

METHOD

ML/ MDL

1,1,1-TRICHLOROETHANE

1,1,2-TRICHLOROETHANE

TRICHLORETHYLENE

VINYL CHLORIDE

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

ACID-EXTRACTABLE COMPOUNDS

P-CHLORO-M-CRESOL

2-CHLOROPHENOL

2,4-DICHLOROPHENOL

2,4-DIMETHYLPHENOL

4,6-DINITRO-O-CRESOL

2,4-DINITROPHENOL

2-NITROPHENOL

4-NITROPHENOL

PENTACHLOROPHENOL

PHENOL

2,4,6-TRICHLOROPHENOL

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

BASE-NEUTRAL COMPOUNDS.

ACENAPHTHENE

ACENAPHTHYLENE

ANTHRACENE

BENZIDINE

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

BENZO(A)PYRENE

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

OMB Number 2040-0086

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

POLLUTANT MAXIMUM DAILY

DISCHARGE

AVERAGE DAILY DISCHARGE

Conc. Units Mass Units Conc. Units Mass Units Number

of

Samples

ANALYTICAL

METHOD

ML/ MDL

3,4 BENZO-FLUORANTHENE

BENZO(GHI)PERYLENE

BENZO(K)FLUORANTHENE

BIS (2-CHLOROETHOXY) METHANE

BIS (2-CHLOROETHYL)-ETHER

BIS (2-CHLOROISO-PROPYL)

ETHER

BIS (2-ETHYLHEXYL) PHTHALATE

4-BROMOPHENYL PHENYL ETHER

BUTYL BENZYL PHTHALATE

2-CHLORONAPHTHALENE

4-CHLORPHENYL PHENYL ETHER

CHRYSENE

DI-N-BUTYL PHTHALATE

DI-N-OCTYL PHTHALATE

DIBENZO(A,H) ANTHRACENE

1,2-DICHLOROBENZENE

1,3-DICHLOROBENZENE

1,4-DICHLOROBENZENE

3,3-DICHLOROBENZIDINE

DIETHYL PHTHALATE

DIMETHYL PHTHALATE

2,4-DINITROTOLUENE

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

1,2-DIPHENYLHYDRAZINE

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

OMB Number 2040-0086

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

POLLUTANT MAXIMUM DAILY

DISCHARGE

AVERAGE DAILY DISCHARGE

Conc. Units Mass Units Conc. Units Mass Units Number

of

Samples

ANALYTICAL

METHOD

ML/ MDL

FLUORANTHENE

FLUORENE

HEXACHLOROBENZENE

HEXACHLOROBUTADIENE

HEXACHLOROCYCLOPENTADIENE

HEXACHLOROETHANE

INDENO(1,2,3-CD)PYRENE

ISOPHORONE

NAPHTHALENE

NITROBENZENE

N-NITROSODI-N-PROPYLAMINE

N-NITROSODI- METHYLAMINE

N-NITROSODI-PHENYLAMINE

PHENANTHRENE

PYRENE

1,2,4-TRICHLOROBENZENE

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

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

END OF PART D.

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

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

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

OMB Number 2040-0086

SUPPLEMENTAL APPLICATION INFORMATION

PART E. TOXICITY TESTING DATA

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

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

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

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

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

show no appreciable toxicity, and testing for acute and/or chronic toxicity, depending on the range of receiving water dilution. Do not include

information on combined sewer overflows in this section. All information reported must be based on data collected through analysis conducted

using 40 CFR Part 136 methods. In addition, this data must comply with QA/QC requirements of 40 CFR Part 136 and other appropriate

QA/QC requirements for standard methods for analytes not addressed by 40 CFR Part 136.

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

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

toxicity reduction evaluation, if one was conducted.

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

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

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

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

complete.

E.1. Required Tests.

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

____chronic ____acute

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

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

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

a. Test information.

Test species & test method number

Age at initiation of test

Outfall number

Dates sample collected

Date test started

Duration

b. Give toxicity test methods followed.

Manual title

Edition number and year of publication

Page number(s)

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

24-Hour composite

Grab

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

Before disinfection

After disinfection

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

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

OMB Number 2040-0086

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

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

Sample was collected:

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

Chronic toxicity

Acute toxicity

g. Provide the type of test performed.

Static

Static-renewal

Flow-through

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

Laboratory water

Receiving water

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

Fresh water

Salt water

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

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

pH

Salinity

Temperature

Ammonia

Dissolved oxygen

l. Test Results.

Acute:

Percent survival in 100%

effluent

% % %

LC50

95% C.I. % % %

Control percent survival % % %

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

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

OMB Number 2040-0086

Chronic:

NOEC % % %

IC25 % % %

Control percent survival % % %

Other (describe)

m. Quality Control/Quality Assurance.

Is reference toxicant data available?

Was reference toxicant test within

acceptable bounds?

What date was reference toxicant test run

(MM/DD/YYYY)?

Other (describe)

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

____Yes ____No If yes, describe: ____________________________________________________ 

____________________________________________________________________________________________

____________________________________________________________________________________________

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

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

results.

Date submitted: ________________ (MM/DD/YYYY)

Summary of results: (see instructions)

____________________________________________________________________________________

____________________________________________________________________________________

END OF PART E.

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

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

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

OMB Number 2040-0086

SUPPLEMENTAL APPLICATION INFORMATION

PART F. INDUSTRIAL USER DISCHARGES AND RCRA/CERCLA WASTES

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

complete Part F.

GENERAL INFORMATION:

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

____Yes ____No

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

industrial users that discharge to the treatment works.

a. Number of non-categorical SIUs. ____________

b. Number of CIUs. ____________

SIGNIFICANT INDUSTRIAL USER INFORMATION:

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

provide the information requested for each SIU.

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

as necessary.

Name: ____________________________________________________________________________________

Mailing Address: ____________________________________________________________________________________

____________________________________________________________________________________

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

_______________________________________________________________________________________________________

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

discharge.

Principal product(s): ________________________________________________________________________________

Raw material(s): ________________________________________________________________________________

F.6. Flow Rate.

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

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

_____________ gpd (_____continuous or ______intermittent)

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

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

_____________ gpd (_____continuous or ______intermittent)

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

a. Local limits ____Yes ____No

b. Categorical pretreatment standards ____Yes ____No

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

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

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

OMB Number 2040-0086

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

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

____Yes ____No If yes, describe each episode.

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

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

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

____Yes ___No (go to F.12.)

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

______Truck ______Rail ______Dedicated Pipe

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

EPA Hazardous Waste Number Amount Units

_________________________ _______________ _______________

_________________________ _______________ _______________

_________________________ _______________ _______________

CERCLA (SUPERFUND) WASTEWATER, RCRA REMEDIATION/CORRECTIVE

ACTION WASTEWATER, AND OTHER REMEDIAL ACTIVITY WASTEWATER:

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

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

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

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

the next five years).

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

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

(Attach additional sheets if necessary).

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

F.15. Waste Treatment.

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

____Yes ____No

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

____________________________________________________________________________________________________

____________________________________________________________________________________________________

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

____Continuous ____Intermittent If intermittent, describe discharge schedule.

____________________________________________________________________________________________________

END OF PART F.

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

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

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

OMB Number 2040-0086

SUPPLEMENTAL APPLICATION INFORMATION

PART G. COMBINED SEWER SYSTEMS

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

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

a. All CSO discharge points.

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

outstanding natural resource waters).

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

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

includes the following information:

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

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

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

d. Locations of flow-regulating devices.

e. Locations of pump stations.

CSO OUTFALLS:

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

G.3. Description of Outfall.

a. Outfall number ________________________________

b. Location ________________________________________________________________

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

________________________________________________________________

(County) (State)

________________________________________________________________

(Latitude) (Longitude)

c. Distance from shore (if applicable) ____________ft.

d. Depth below surface (if applicable) ____________ft.

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

____Rainfall ____CSO pollutant concentrations ____CSO frequency

____CSO flow volume ____Receiving water quality

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

G.4. CSO Events.

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

__________ events (___ actual or ___ approx.)

b. Give the average duration per CSO event.

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

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

OMB Number 2040-0086

c. Give the average volume per CSO event.

__________ million gallons (_____ actual or _____ approx.)

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

__________ inches of rainfall

G.5. Description of Receiving Waters.

a. Name of receiving water: ______________________________________________________________________________

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

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

c. Name of State Management/River Basin: _______________________________________________________________

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

G.6. CSO Operations.

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

intermittent shell fish bed closings, fish kills, fish advisories, other recreational loss, or violation of any applicable State water quality standard).

______________________________________________________________________________________________

______________________________________________________________________________________________

END OF PART G.

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

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

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