Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

United States 

Environmental Protection Agency 

Office of Water 

Washington, D.C. 

EPA Form 3510-2D 

Revised <INSERT DATE> 

Water Permits Division 

Application Form 2D 

New Dischargers - Wastewater 

Discharge Information 

NPDES Permitting Program 

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

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

This document is being distributed for comment purposes only. Comments and 

suggestions regarding this draft document should be submitted through electronic 

comments to http://www.regulations.gov.

Note: Complete this form and Form 1 if your facility is a new manufacturing, commercial, mining, or 

silvicultural facility that has yet to commence discharge of process wastewater.

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Paperwork Reduction Act Notice 

The U.S. Environmental Protection Agency estimates the average burden to complete Form 2D to 

average 32 hours for some minor facilities and 46 hours for some major facilities, with a weighted 

average for major and minor facilities of 33.2 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), 

U.S. Environmental Protection Agency, 1200 Pennsylvania Avenue, NW, Washington, DC 20460 and to 

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

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

For Comment Only
2D-1 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

FORM 2D—INSTRUCTIONS 

General Instructions 

Who Must Complete Form 2D? 

Applicants who answered “yes” to Item 1.2.5 on Form 1 must 

complete Form 2D. This means that your facility is a new 

manufacturing, commercial, mining, or silvicultural facility that has 

yet to commence discharge of process wastewater. 

Where to File Your Completed Forms? 

Submit your completed application package (Forms 1 and 2D) to 

your National Pollutant Discharge Elimination System (NPDES) 

permitting authority. Consult Exhibit 1–1 of the “General 

Instructions” of Form 1 to determine your NPDES permitting 

authority. 

Public Availability of Submitted Information 

EPA will make information provided on the various NPDES permit 

application forms available to the public for inspection and copying 

upon request. No information on Form 2D (or related attachments) 

may be claimed as confidential. 

You may make a claim of confidentiality for any information that you 

submit to EPA that goes beyond the information required by Form 

2D. Note that NPDES permitting authorities will deny claims for 

treating any effluent data (estimated or actual) as confidential. If 

you do not assert a claim of confidentiality at the time you submit 

your information to the NPDES permitting authority, EPA may make 

the information available to the public without further notice to you. 

EPA will handle claims of confidentiality in accordance with the 

Agency’s business confidentiality regulations at Part 2 of Title 40 of 

the Code of Federal Regulations (CFR). 

Completion of Forms 

Print or type in the specified areas only. If you do not have enough 

space on the form to answer a question, you may continue on 

additional sheets, as necessary, using a format consistent with the 

form. 

Provide your EPA Identification Number from the Federal Registry 

Service and facility name at the top of each page of Form 2D and 

any attachments. If you do not know your EPA Identification 

Number, contact your NPDES permitting authority. See Exhibit 1–1 

of the “General Instructions” of Form 1 for contact information. 

Additionally, for Tables A through E, provide the applicable Outfall 

Number at the top of each page. 

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

to skip the item. If the form directs you to respond to an item that 

does not apply to your facility or activity, enter “NA” for “not 

applicable” to show that you considered the item and determined a 

response was not necessary for your facility. 

The NPDES permitting authority will consider your application 

complete when it and any supplementary material are received and 

completed according to the authority’s satisfaction. The NPDES 

permitting authority will judge the completeness of any application 

independently of the status of any other permit application or permit 

for the same facility or activity.

Follow-up Requirements 

Form 2D requires that you submit estimated data regarding your 

effluent. Note that no later than 18 months after you begin 

discharging from the proposed facility, you must complete and 

submit Section 7 of NPDES Application Form 2C. However, you 

need not complete those portions of Section 7 that require tests you 

have already performed under the discharge monitoring 

requirements of your NPDES permit. In addition, your NPDES 

permitting authority may waive the requirements of Form 2C, 

Section 7 if you make the demonstrations required under 40 CFR 

122.22(g)(7)(i)(B) and 122.21(g)(9). 

Definitions 

Definitions of all significant terms used in Form 2D are in the 

“Glossary,” which follows the “General Instructions” in Form 1. 

Line-By-Line Instructions 

Section 1. Expected Outfall Location 

Item 1.1. Identify each of the facility’s outfall structures by number. 

For each outfall, specify the latitude and longitude, method of 

collection, and name of the receiving water. The application form 

provides reporting space for three outfalls. If your facility has more 

than this number, attach additional sheets as necessary. The 

location of each outfall (i.e., where the coordinates are collected) 

shall be the point where the discharge is released into a water of 

the United States. In the column marked “Collection Method 

Information,” indicate the following: (a) horizontal collection method, 

which is the type of method/device used to identify the coordinates 

(e.g., global positioning system or GPS device, census block 

centroid, an address, State Plane Coordinate System or SPCS, 

etc.); (b) scale of your source map or photo if applicable (e.g., the 

proportional distance on the ground for one unit of measure 

typically expressed in ratio form such as 1:24,000); and 

(c) horizontal reference datum (i.e., the coordinate reference 

system) to which your coordinates relate. 

GPS devices are commonly used to electronically record the 

latitude and longitude coordinates of a property. It is also possible 

to use geographic information systems (e.g., ArcView), online 

sources (e.g., U.S. Geological Survey or USGS) to identify 

coordinates. The online services require that you enter a property 

address, the nearest intersection, or zip code. The system then 

generates the coordinates. The horizontal collection method for 

such sources is “Interpolation–Satellite.” You would not report a 

source map scale if you used a GPS device or one of the online 

systems. For the horizontal reference datum, you would report one 

of the following three options: 

1. North American Datum of 1927 (NAD27): This datum was based 

on the ground survey in Europe and North America in the 19th

century. NAD27 was the standard for many years because the 

USGS published its topographic maps in this datum. If you are 

reporting a location using a USGS 7.5-minute map, NAD27 is 

your default datum.

2. North American Datum of 1983 (NAD83): NAD83 updated 

NAD27 with current measurements using radio astronomy and 

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

FORM 2D—INSTRUCTIONS CONTINUED 

satellite observations. When the USGS began publishing digital 

data, the NAD83 was used which provided a more accurate 

representation of the earth’s shape and a more accurate 

depiction of the location of objects on the earth.

3. World Geodetic System of 1984 (WGS84): This datum was 

developed from the measurements calculated in NAD83. If you 

used a GPS to calculate your latitude/longitude coordinates, 

WGS84 is the default datum. 

If you need further guidance in responding to Item 1.1, refer to 

http://www.epa.gov/geospatial/latitudelongitude-data-standard. 

Section 2. Expected Discharge Date

Item 2.1. Report the expected date the facility will commence 

discharging (month, day, and year). 

Section 3. Average Flows and Treatment

Item 3.1. For each outfall, report the operations expected to 

contribute wastewater to the effluent and an estimated average flow 

from each. Briefly describe the planned wastewater treatment for 

each operation or list the applicable treatment code(s) from Exhibit 

2D-1, located at the end of these Instructions. Finally, for each 

operation, note the ultimate disposal of any solid or liquid wastes 

not expected to be discharged. 

Section 4. Line Drawing 

Item 4.1. Attach a line drawing depicting the expected water flow 

through your facility, from intake to discharge. Indicate the sources 

of intake water (e.g., city, well, stream, other); all sources of 

wastewater contributing to the effluent, including process and 

production areas, sanitary flows, cooling water, and stormwater 

runoff; and labeled treatment units. You may group similar 

operations into a single unit. 

Construct a water balance on the line drawing by showing average 

flows (specify units) between intakes, operations, treatment units, 

and outfalls. Show all significant losses of water to products, the 

atmosphere, and discharge. You should use actual measurements 

wherever available; otherwise use your best estimate. If you are 

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

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

amount of any sources of water and any collection and treatment 

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

Exhibit 2D–2 at the end of these Instructions. 

Section 5. Intermittent or Seasonal Flows 

Item 5.1. Specify whether any of the expected discharges 

described in Sections 1 and 3 will be intermittent or seasonal. If 

“yes,” continue to Item 5.2. If “no,” skip to Section 6. 

Item 5.2. List applicable outfalls that will have intermittent or 

seasonal flows. For each, indicate the operations that will contribute 

to the flow. For each operation, indicate the average days per week 

and average months per year the discharge will occur, the 

maximum daily flow rate, maximum total volume, and the duration 

of the discharge in days. The estimated flow rate and volume 

should not include stormwater runoff, spillage, or leaks. A discharge 

is intermittent if it occurs with interruptions during the 

operating hours of the facility. Discharges caused by routine 

maintenance shutdowns, process changes, or other similar 

activities are not considered to be intermittent. A discharge is 

seasonal if it occurs only during certain parts of the year. The 

frequency is the average recurrence rate of the discharge (in days 

per week and months per year). The duration is the average value 

of the time duration during which the discharge occurs (in days). 

The maximum daily flow rate is the highest daily value and should 

be reported in million gallons per day (mgd). Maximum total volume 

means the total volume of any one discharge within 24 hours and is 

measured in units such as gallons. 

Section 6. Production 

Applicable ELGs 

Item 6.1. Indicate whether any effluent limitation guidelines (ELGs) 

promulgated under Section 304 of the Clean Water Act (CWA) 

apply to your facility. All ELGs promulgated by EPA appear in the 

Federal Register and are published annually in 40 CFR 

Subchapter N. An ELG applies if you have any operations 

contributing process wastewater in any subcategory covered by 

New Source Performance Standards (NSPS). If you are unsure 

whether you are covered by a promulgated ELG, consult your 

NPDES permitting authority (see Exhibit 1–1 of the “General 

Instructions” of Form 1). You must check “yes” if an applicable ELG 

has been promulgated, even if the ELG is being contested in court. 

If you believe that a promulgated ELG has been remanded for 

reconsideration by a court and does not apply to your operations, 

you may answer “no” to item 6.1 and skip to Section 7. 

Item 6.2. Complete Item 6.2 by indicating the applicable ELG 

category, ELG subcategory, and corresponding regulatory citation. 

See example below. 

Item 6.3. Indicate whether the limitations in the applicable ELGs are 

expressed in terms of production (or other measure of operation). 

An ELG is expressed in terms of production (or other measure of 

operation) if the limitation is expressed as mass of pollutant per 

operational parameter (e.g., “pounds of biological oxygen demand 

per cubic foot of logs from which bark is removed,” or “pounds of 

total suspended solids per megawatt hour of electrical energy 

consumed by smelting furnace.”). An example of an ELG not 

expressed in terms of a measure of operation is one which limits 

the concentration of pollutants. If you answer “no” to this item, skip 

to Section 7. 

Item 6.4. For each applicable outfall to which an applicable 

production-based ELG applies, list the estimated level of production 

(projection of actual production level, not design), for each of the 

first three years of operation. The estimated production level must 

be a long-term average estimate (e.g., average production on an Applicable ELGs

6.2 ELG Category ELG 

Subcategory 

Regulatory 

Citation 

Pulp, Paper, 

and 

Paperboard 

Point Source 

Category

Secondary Fiber 

Non-Deink 

Subcategory

40 CFR Part 

430, Subpart J 

For Comment Only
2D-3 

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FORM 2D—INSTRUCTIONS CONTINUED

annual basis). If production will vary depending on long-term shifts 

in operating schedule or capacity, you may report alternative 

production estimates, but you must provide the basis for such 

alternatives. If known, report quantities in units of measurements 

used in the applicable ELG. If an ELG specifies a method for 

estimating production, you must follow that method. 

Section 7. Effluent Characteristics and Tables A through E 

General Information. Section 7 requires you to report estimated

flow data for the parameters and pollutants listed in Tables A 

through E, located at the end of Form 2D. You are not required to 

conduct actual sampling and analysis at this time. If, however, data 

from such analyses are available, you must report those data. Note 

that no later than 18 months after you begin discharging from the 

proposed facility, you must complete and submit quantitative data 

for the pollutants and parameters in Tables A through E. However, 

you need not report results for tests you have already performed 

and reported under the discharge monitoring requirements of your 

NPDES permit. 

Complete a set of tables (Tables A through E) for each outfall at 

your facility. Be sure to note the EPA Identification Number, facility 

name, and outfall number at the top of each table page and any 

associated attachments. 

Tables A through D require you to report estimated effluent data, 

with some exceptions, as discussed further below. Base your 

estimates on available in-house or contractors’ engineering reports 

or any other studies performed on the proposed facility. Table E 

requires you to report quantitative data for the pollutants listed, but 

only if it is already available. 

Several tables require you to provide estimates for pollutants you 

believe will be present in your discharge or will be limited directly by 

an ELG or indirectly through promulgated limitations on an indicator 

pollutant. 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, intermediate and 

final products, byproducts, and any analyses of any pollutant (you 

are required to report it). 

For those pollutants you believe will be present in the discharge, 

you are to provide the maximum daily and average daily 

concentration and total mass and the source of the information. Use 

the following codes to report your source information: 

Data Source 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 5 and specify on 

the table 

You may report some or all of your estimates (or actual data when 

available) by attaching separate sheets of paper instead of 

completing Tables A through E for each of your outfalls, so long as 

the sheets contain all of the required information and are similar in 

format to Tables A through E. 

Reporting of Intake Data 

If you expect a pollutant to be present solely because of its 

presence in your intake water, you must mark “yes” under the 

“Intake Water” column of Tables A through D. If you wish to obtain 

credits for pollutants or parameters present in your intake water, 

insert a separate sheet with a short statement of why you believe 

you are eligible (see 40 CFR 122.45(g)). 

Reporting of Effluent Data 

Report all estimated pollutant or parameter levels as concentration 

and as total mass, with the exception of discharge flow, 

temperature, and pH. 

Use the following abbreviations in the columns requiring “units” in 

Tables A through E. 

Concentration Mass 

ppm = parts per million lbs = pounds 

mg/L = milligrams per liter ton = Tons (English tons) 

ppb = parts per billion mg = milligrams 

μg/L = micrograms per liter g = grams 

MPN = most probable number kg = kilograms 

per 100 milliliters T = tonnes (metric tons)

Conventional and Non-Conventional Parameters 

Items 7.1 through 7.3 and Table A. 

Table A and Item 7.1. All applicants are required to complete 

Table A for each outfall, including outfalls discharging only 

noncontact cooling water or nonprocess water unless a waiver has 

been received or requested from the NPDES permitting authority. 

For each parameter listed on Table A, indicate whether a waiver 

has been requested. If you have requested a waiver for all

pollutants for a given outfall, check the box indicating this at the top 

of Table A. 

To request a waiver, submit a written request to the NPDES 

permitting authority in advance or with the permit application. The 

written request should specify the parameters that should be 

waived and for what outfall(s) and why. The NPDES permitting 

authority may waive Table A requirements upon a determination 

that less stringent reporting requirements are adequate to support 

issuance of an NPDES permit. Attach a copy of any waiver 

approval notice(s) received, if applicable, to this application. 

Answer Item 7.1 by indicating if you are requesting a waiver for any 

of your outfalls. If “yes,” continue to Item 7.2. Otherwise, complete 

Table A by estimating your maximum daily and average daily 

discharge. Provide the source(s) of your information. Also on 

Table A, indicate whether you believe each of the parameters will 

be present in the facility’s intake water. See “Reporting of Intake 

Data” above for further information. Skip to Item 7.3. 

Item 7.2. Indicate the outfalls for which you have requested a 

waiver. 

Item 7.3. Indicate if you have provided estimates or actual data for 

all Table A parameters for each of your outfalls for which a waiver 

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

FORM 2D—INSTRUCTIONS CONTINUED

has not been requested and attach the results to your application 

package. 

Certain Conventional and Non-Conventional Pollutants 

Items 7.4 through 7.6 and Table B. Complete one table for each 

outfall, including outfalls discharging only noncontact cooling water 

or nonprocess wastewater. Check () the box at the top of Table B 

if you believe all pollutants listed will be absent in the discharge. If 

so, you do not need to complete Table B for the noted outfall. (You 

still need to complete Items 7.4 through 7.6.) Otherwise, for each 

pollutant listed in Table B, indicate whether you expect it will be 

present or absent in the discharge or whether the pollutant is limited 

directly by an ELG or indirectly through promulgated limitations or 

an indicator pollutant. For example, total suspended solids is used 

as an indicator to control the discharge of iron and aluminum. Next, 

provide an estimated maximum daily and average daily value, 

including the source of the information. If you have quantitative data 

available, report it. Also on Table B, indicate whether you believe 

the listed pollutants will be present in the facility’s intake water. See 

“Reporting of Intake Data” above for further information. Answer 

“yes” to Items 7.4 through 7.6 once you have completed the above 

tasks.

Toxic Metals, Total Cyanide, and Total Phenols 

Items 7.7 and 7.8 and Table C. Complete one table for each 

outfall, including outfalls discharging only noncontact cooling water 

or nonprocess wastewater. Check () the box at the top of Table C 

if you believe all pollutants listed will be absent in the discharge. If 

so, you do not need to complete Table C for the noted outfall 

(unless you have quantitative data available). You still need to 

respond to Items 7.7 and 7.8, however. Otherwise, indicate whether 

you believe each pollutant on Table C will be present or absent in 

your discharge for each applicable outfall. For those pollutants you 

believe will be present, provide an estimated maximum daily and 

average daily value and source of the information. (Provide 

quantitative data if you have it available.) Also, on Table C, indicate 

whether you believe the pollutant is or will be present in your 

facility’s intake water. See “Reporting of Intake Data” above for 

further information. Answer “yes” to Items 7.7 and 7.8 when you 

have completed the above tasks. 

Organic Toxic Pollutants 

(Gas Chromatography/Mass Spectrometry or GC/MS Fractions) 

Items 7.9 through 7.11 and Table D 

Item 7.9. Applicants are exempt from the reporting requirements 

associated with Table D if they expect to have gross sales of less 

than $100,000 per year for the next three years or if they are a coal 

mine with expected average production of less than 100,000 tons of 

coal per year. If you believe you meet one of the criterions noted, 

answer “yes” to Item 7.9, check () the small business box at the 

top of Table D, and attach projected sales or production figures. 

Skip to Item 7.12 when through. 

The sales or production figures must be for the facility that will be 

the source of the discharge. The data should not be limited only to 

production or sales for the process or processes that will contribute 

to the discharge, unless those are the only processes at the facility. 

For sales data, where intracorporate transfers of goods and 

services will be involved, the transfer price per unit should 

approximate market process 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. You may accomplish this by using the 

gross national product price deflator (second quarter of 1980 = 

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

Commerce, Bureau of Economic Analysis at 

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

Item 7.10 and 7.11 and Table D. Complete one table for each 

outfall, including outfalls discharging only noncontact cooling water 

or nonprocess wastewater. Check () the box at the top of Table D 

if you believe all pollutants listed will be absent in the discharge 

from the outfall. If so, you do not need to complete Table D for the 

noted outfall (unless you have quantitative data available). 

Otherwise, for each pollutant listed, indicate whether you believe it 

will be present or absent in the discharge. For those you believe will 

be present, provide an estimated maximum daily and average daily 

value and the source of the information. Also, on Table D, indicate 

whether you believe the pollutant is or will be present in your 

facility’s intake water. See “Reporting of Intake Data” above for 

further information. Finally, answer “yes” to Items 7.10 and 7.11 

when you have completed the above tasks. 

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) 

Item 7.12 

Item 7.12. Answer whether the facility uses or manufactures one or 

more of the 2,3,7,8-TCDD congeners listed below or if you know or 

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

from any of your outfalls: 

A. 2,4,5-trichlorophenoxy acetic acid (2,4,5-T) (CAS # 93-765); 

B. 2-(2,4,5-trichlorophenoxy) propanoic acid (Silvex, 2,4,5-TP) (CAS 

# 93-72-1); 

C. 2-(2,4,5-trichlorophenoxy) ethyl 2,2-dichloropropionate (Erbon) 

(CAS # 136-25-4); 

D. 0,0-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). 

Certain Hazardous Substances and Asbestos 

Items 7.13 through 7.14 and Table E 

Table E. Complete Table E for each outfall. Check () the box at 

the top of Table E if you believe all pollutants listed will be absent in 

the discharge. Otherwise, for each pollutant listed in Table E, 

indicate whether you believe it will be present or absent in the 

discharge. If you have quantitative estimates available for any of 

the pollutants listed, provide the maximum daily and average daily 

average value and the source of the information. Also, on Table E, 

if you believe the pollutant is or will be present in your facility’s 

intake water, state so in the “Reason Pollutant Believed Present in 

Discharge” column. 

For Comment Only
2D-5 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

FORM 2D—INSTRUCTIONS CONTINUED

Item 7.13. Check whether for each of your outfalls you have 

indicated whether you know or have reason to believe that any 

pollutants listed in Table E are discharged. 

Item 7.14. Indicate whether you have for each of your outfalls 

completed and attached Table E to the application describing the 

reasons the applicable pollutants are expected to be discharged 

and providing quantitative data if available. 

Intake Credits 

Item 7.15. Answer whether you are seeking to obtain credits for any 

of the pollutants or parameters listed in Section 7 (Tables A through 

E) in your intake water for any of the facility’s outfalls. 

Section 8. Engineering Report 

Item 8.1. Indicate if any technical evaluations have been conducted 

of your wastewater treatment, including engineering reports or pilot 

plant studies. If “yes,” continue to Item 8.2. If “no,” skip to Item 8.3. 

Item 8.2. Attach the technical evaluation(s) you considered when 

responding to Item 8.1 and any related documentation to Form 2D 

and then answer “yes” to Item 8.2. The NPDES permit writer will 

use this information to determine appropriate treatment methods 

and associated permit conditions and limits. 

Item 8.3. Answer “yes” if you are aware of any existing plant(s) that 

resemble your production processes, wastewater constituents, or 

wastewater treatment. If you are unaware of such plants, answer 

“no” and skip to Section 9. 

Item 8.4. Provide the name and location of any existing plant(s) that 

resemble(s) your production facility. You do not need to conduct 

any studies to respond to this item. 

Section 9. Other Information 

Item 9.1. Indicate whether you have attached to the application any 

optional information that you would like considered as part of the 

application review process. These should be items beyond those 

you have already noted as being included in the package. Skip to 

Section 10 if you do not have further information to provide. 

Item 9.2. List the additional materials attached and note why you 

think they should be considered by the NPDES permitting authority 

when reviewing your application and developing your permit. 

Section 10. Checklist and Certification Statement 

Item 10.1. Review the checklist provided. In Column 1, mark the 

sections of Form 2D that you have completed and are submitting 

with your application. For each section, indicate in column 2 

whether you are submitting attachments. 

Item 10.2. The Clean Water Act provides for severe penalties for 

submitting false information on this application form. Section 

309(c)(2) of the Clean Water Act provides that “Any person who 

knowingly makes any false statement, representation, or 

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

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

than six months or both.” 

FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS 

APPLICATION TO BE SIGNED AS FOLLOWS: 

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

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

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

charge of a principal business function, or any person who 

performs similar policy- or decision-making functions for the 

corporation, or (ii) the manager of one or more manufacturing, 

production, or operating facilities, provided, the manager is 

authorized to make management decisions which govern the 

operation of the regulated facility having the explicit or implicit 

duty of making major capital investment recommendations, and 

initiating and directing other comprehensive measures to assure 

long term environmental compliance with environmental laws 

and regulations; the manager can ensure that the necessary 

systems are established or actions taken to gather complete 

and accurate information for permit application requirements; 

and where authority to sign documents has been assigned or 

delegated to the manager in accordance with corporate 

procedures. 

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

the proprietor, respectively. 

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

either a principal executive officer or ranking elected official. 

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

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

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

the overall operations of a principal geographic unit of the 

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

END

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

attachments to your NPDES permitting authority.

For Comment Only
2D-6 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Exhibit 2D–1. Codes for Treatment Units and Disposal of Wastes Not Discharged 

1. PHYSICAL TREATMENT PROCESSES 

1–A ................. Ammonia Stripping 

1–B ................. Dialysis 

1–C ................ Diatomaceous Earth Filtration 

1–D ................ Distillation 

1–E ................. Electrodialysis 

1–F ................. Evaporation 

1–G ................ Flocculation 

1–H ................ Flotation 

1–I .................. Foam Fractionation 

1–J ................. Freezing 

1–K ................. Gas–Phase Separation 

1–L ................. Grinding (Comminutors) 

1–M ................ Grit Removal 

1–N ................ Microstraining 

1–O ................ Mixing 

1–P ................ Moving Bed Filters 

1–Q ................ Multimedia Filtration 

1–R ................ Rapid Sand Filtration 

1–S ................ Reverse Osmosis (Hyperfiltration) 

1–T ................ Screening 

1–U ................ Sedimentation (Settling) 

1–V ................ Slow Sand Filtration 

1–W ............... Solvent Extraction 

1–X ................ Sorption 

2. CHEMICAL TREATMENT PROCESSES 

2–A ................. Carbon Adsorption 

2–B ................. Chemical Oxidation 

2–C ................ Chemical Precipitation 

2–D ................ Coagulation 

2–E ................. Dechlorination 

2–F ................. Disinfection (Chlorine) 

2–G ................ Disinfection (Ozone) 

2–H ................ Disinfection (Other) 

2–I .................. Electrochemical Treatment 

2–J ................. Ion Exchange 

2–K ................ Neutralization 

2–L ................. Reduction 

3. BIOLOGICAL TREATMENT PROCESSES 

3–A ................. Activated Sludge 

3–B ................. Aerated Lagoons 

3–C ................ Anaerobic Treatment 

3–D ................ Nitrification–Denitrification 

3–E ................ Pre-Aeration 

3–F ................ Spray Irrigation/Land Application 

3–G ................ Stabilization Ponds 

3–H ................ Trickling Filtration 

4. OTHER PROCESSES 

4–A ................. Discharge to Surface Water 

4–B ................. Ocean Discharge Through Outfall 

4–C ............... Reuse/Recycle of Treated Effluent 

4–D ............... Underground Injection 

5. SLUDGE TREATMENT AND DISPOSAL PROCESSES 

5–A ................. Aerobic Digestion 

5–B ................. Anaerobic Digestion 

5–C ................ Belt Filtration 

5–D ................ Centrifugation 

5–E ................. Chemical Conditioning 

5–F ................. Chlorine Treatment 

5–G ................ Composting 

5–H ................ Drying Beds 

5–I .................. Elutriation 

5–J ................. Flotation Thickening 

5–K ................. Freezing 

5–L ................. Gravity Thickening 

5–M ................ Heat Drying 

5–N ................ Heat Treatment 

5–O ................ Incineration 

5–P ................ Land Application 

5–Q ................ Landfill 

5–R ................ Pressure Filtration 

5–S ................ Pyrolysis 

5–T ................ Sludge Lagoons 

5–U ................ Vacuum Filtration 

5–V ................ Vibration 

For 

5–W ............... Wet Oxidation 

Comment Only
2D-7 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Exhibit 2D–2. Example Line Drawing 

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

For Comment Only
EPA Form 3510-2D (Revised <INSERT DATE>) Page 1

EPA Identification Number Facility Name Form Approved

OMB No. <INSERT NO.> 

Form Expires <INSERT DATE> 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Form 

2D 

NPDES

U.S. Environmental Protection Agency 

Application for NPDES Permit to Discharge Wastewater 

NEW MANUFACTURING, COMMERCIAL, MINING, OR SILVICULTURAL FACILITY THAT HAS 

NOT YET COMMENCED DISCHARGE OF PROCESS WASTEWATER

SECTION 1. EXPECTED OUTFALL LOCATION (40 CFR 122.21(k)(1)) Outfall Location 

1.1 Provide information on each of the facility’s outfalls in the table below.

Outfall 

Number Receiving Water Name Latitude Longitude 

Degrees Minutes Seconds Degrees Minutes Seconds 

 

Collection Method Information 

Horizontal Collection Method (Type of 

method/device used to identify the coordinates)

Scale (Proportional distance on the ground for 

one unit of measure) Not Applicable

Horizontal Reference Datum

(Coordinate reference system)

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

Outfall 

Number Receiving Water Name Latitude Longitude 

Degrees Minutes Seconds Degrees Minutes Seconds 

 

Collection Method Information 

Horizontal Collection Method (Type of 

method/device used to identify the coordinates)

Scale (Proportional distance on the ground for 

one unit of measure) Not Applicable

Horizontal Reference Datum

(Coordinate reference system)

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

Outfall 

Number Receiving Water Name Latitude Longitude 

Degrees Minutes Seconds Degrees Minutes Seconds 

 

Collection Method Information 

Horizontal Collection Method (Type of 

method/device used to identify the coordinates)

Scale (Proportional distance on the ground for 

one unit of measure) Not Applicable

Horizontal Reference Datum

(Coordinate reference system)

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

SECTION 2. EXPECTED DISCHARGE DATE (40 CFR 122.21(k)(2)) Expected Discharge Date 

2.1 Month Day Year 

 

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

EPA Identification Number Facility Name Form Approved

OMB No. <INSERT NO.> 

Form Expires <INSERT DATE> 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

SECTION 3. AVERAGE FLOWS AND TREATMENT (40 CFR 122.21(k)(3)(i)) Average Flows and Treatment 

3.1 For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional pages as 

necessary. 

Outfall Number _________ 

Operations Contributing to Flow 

Operation Average Flow 

mgd 

mgd 

mgd 

mgd 

mgd 

Treatment Units 

Description 

(Include size, flow rate through each treatment unit, 

retention time, etc.)

Code from 

Exhibit 2D-1 

Final Disposal of Solid or Liquid 

Wastes Other Than by Discharge 

Outfall Number _________ 

Operations Contributing to Flow 

Operation Average Flow 

mgd 

mgd 

mgd 

mgd 

mgd 

Treatment Units 

Description 

(Include size, flow rate through each treatment unit, 

retention time, etc.)

Code from 

Exhibit 2D-1 

Final Disposal of Solid or Liquid 

For 

Wastes Other Than by Discharge 

Comment Only
EPA Form 3510-2D (Revised <INSERT DATE>) Page 3

EPA Identification Number Facility Name Form Approved

OMB No. <INSERT NO.> 

Form Expires <INSERT DATE> 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Average Flows and Treatment Continued 

3.1 Outfall Number __________ 

Cont. Operations Contributing to Flow 

Operation Average Flow 

mgd 

mgd 

mgd 

mgd 

mgd 

Treatment Units 

Description 

(Include size, flow rate through each treatment unit, 

retention time, etc.)

Code from 

Exhibit 2D-1 

Final Disposal of Solid or Liquid 

Wastes Other Than by Discharge 

SECTION 4. LINE DRAWING (40 CFR 122.21(k)(3)(ii)) Line Drawing 

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

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

 Yes  No 

SECTION 5. INTERMITTENT OR SEASONAL FLOWS (40 CFR 122.21(k)(3)(iii)) Intermittent or Seasonal Flows 

5.1 Except for stormwater runoff, leaks, or spills, are any expected discharges described in Sections 1 and 3 intermittent or 

seasonal?

 Yes  No  SKIP to Section 6. 

5.2 Provide information on intermittent or seasonal flows for each applicable outfall. Attach additional pages, if necessary. 

Outfall 

Number 

Operations 

(list) 

Frequency Rate and Volume 

Average Duration 

Days/Week 

Average 

Months/Year 

Maximum Daily 

Discharge 

Maximum Total 

Volume 

days/week months/year mgd gallons days

 days/week months/year mgd gallons days

 days/week months/year mgd gallons days

Outfall 

Number 

Operations 

(list) 

Frequency Rate and Volume 

Average Duration 

Days/Week 

Average 

Months/Year 

Maximum Daily 

Discharge 

Maximum Total 

Volume 

days/week months/year mgd gallons days

 days/week months/year mgd gallons days

 days/week months/year mgd gallons days

For Comment Only
EPA Form 3510-2D (Revised <INSERT DATE>) Page 4

EPA Identification Number Facility Name Form Approved

OMB No. <INSERT NO.> 

Form Expires <INSERT DATE> 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Intermittent or Seasonal 

Flows Continued 

Outfall 

Number 

Operations 

(list) 

Frequency Rate and Volume 

Average Duration 

Days/Week 

Average 

Months/Year 

Maximum Daily 

Discharge 

Maximum Total 

Volume 

days/week months/year mgd gallons days

 days/week months/year mgd gallons days

 days/week months/year mgd gallons days

SECTION 6. PRODUCTION (40 CFR 122.21(k)(4)) Production 

6.1 Do any ELGs promulgated by EPA under CWA Section 304 apply to your facility? 

 Yes  No  SKIP to Section 7. 

6.2 

Provide the following information on applicable ELGs.

ELG Category ELG Subcategory Regulatory Citation 

 

 

6.3 Are the limitations in the applicable ELGs expressed in terms of production (or other measure of operation)? 

 Yes  No  SKIP to Section 7. 

6.4 Provide an expected measure of average daily production expressed in terms and units of applicable ELGs. 

Expected Actual Average Daily Production for First Three Years 

Outfall 

Number Year Operation, Product, or Material Quantity Per Day 

(Note basis if applicable.) Unit of Measure 

Year 1 

Year 2 

Year 3 

Year 1 

Year 2 

Year 3 

Year 1 

Year 2 

Year 3 

For Comment Only
EPA Form 3510-2D (Revised <INSERT DATE>) Page 5

EPA Identification Number Facility Name Form Approved

OMB No. <INSERT NO.> 

Form Expires <INSERT DATE> 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

SECTION 7. EFFLUENT CHARACTERISTICS (40 CFR 122.21(k)(5)) Effluent Characteristics 

See the Instructions to determine the parameters and pollutants you are required to monitor and, in turn, the tables you must 

complete. Note that not all applicants need to complete each table. 

Table A. Conventional and Non-Conventional Parameters 

7.1 Are you requesting a waiver from your NPDES permitting authority for one or more of the Table A parameters for any of 

your outfalls? 

 Yes  No  SKIP to Item 7.3. 

7.2 If yes, indicate the applicable outfalls below. Attach waiver request and other required information to the application. 

Outfall Number ________ Outfall Number ________ Outfall Number ________ 

7.3 Have you have provided estimates or actual data for all Table A parameters for each of your outfalls for which a waiver 

has not been requested and attached the results to this application package. 

 Yes 

No; A waiver has been requested from my 

NPDES permitting authority for all parameters 

at all outfalls. 

Table B. Certain Conventional and Non-Conventional Pollutants 

7.4 Have you checked “Believed Present” for all pollutants listed in Table B that are limited directly or indirectly by an 

applicable ELG? 

 Yes  No 

7.5 Have you checked “Believed Present” or “Believed Absent” for all remaining pollutants listed in Table B? 

 Yes  No 

7.6 Have you provided estimated data for those Table B pollutants for which you have indicated are “Believed Present” in 

your discharge? 

 Yes  No 

Table C. Toxic Metals, Total Cyanide, and Total Phenols

7.7 Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed on Table C for 

all outfalls? 

 Yes  No 

7.8 Have you completed Table C by providing estimated data for pollutants you indicated are “Believed Present”, including 

the source of the information, for each applicable outfall? 

 Yes  No 

Table D. Organic Toxic Pollutants (GS/MS Fractions)

7.9 Do you qualify for a small business exemption under the criteria specified in the Instructions? 

 Yes  Note that you qualify at the top of Table D 

then SKIP to Item 7.12.  No 

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

all outfalls? 

 Yes  No 

7.11 Have you completed Table D by providing estimated data for pollutants you indicated are “Believed Present”, including 

the source of the information, for each applicable outfall? 

 Yes  No 

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) 

7.12 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the Instructions, or do you 

know or have reason to believe that TCDD is or may be present in effluent from any of your outfalls? 

 Yes  No 

For Comment Only
EPA Form 3510-2D (Revised <INSERT DATE>) Page 6

EPA Identification Number Facility Name Form Approved

OMB No. <INSERT NO.> 

Form Expires <INSERT DATE> 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

Effluent Characteristics Continued 

Table E. Certain Hazardous Substances and Asbestos 

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

all outfalls? 

 Yes  No 

7.14 Have you completed Table E by reporting the reason the pollutants are expected to be present and available

quantitative data for pollutants you indicated are “Believed Present” for each applicable outfall? 

 Yes  No 

Intake Credits, Tables A through E 

7.15 Are you applying for net credits for the presence of any of the pollutants on Tables A through E for any of your outfalls? 

 Yes  Consult with your NPDES permitting 

authority.  No 

SECTION 8. ENGINEERING REPORT (40 CFR 122.21(k)(6)) Engineering Report 

8.1 Do you have any technical evaluations of your wastewater treatment, including engineering reports or pilot plant 

studies? 

 Yes  No  SKIP to Item 8.3. 

8.2 Have you provided the technical evaluation and all related documents to this application package? 

 Yes  No 

8.3 Are you aware of any existing plant(s) that resemble production processes, wastewater constituents, or wastewater 

treatment at your facility? 

 Yes  No  SKIP to Section 9. 

Engineering Report 

Continued 

8.4 Provide the name and location of the similar plants. 

Name of Similar Plants Location of Similar Plants 

 

SECTION 9. OTHER INFORMATION (40 CFR 122.21(k)(7)) Other Information 

9.1 Have you attached any optional information that you would like considered as part of the application review process 

(i.e., material beyond that which you have already noted in the application as being attached)? 

 Yes  No  SKIP to Section 10. 

9.2 List the additional items and briefly note why you have included them. 

1.

2.

3.

4.

For 

5.

Comment Only
EPA Form 3510-2D (Revised <INSERT DATE>) Page 7

EPA Identification Number Facility Name Form Approved

OMB No. <INSERT NO.> 

Form Expires <INSERT DATE> 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

SECTION 10. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d)) Checklist and Certification Statement 

10.1 In Column 1 below, mark the Form 2D sections you have completed and are submitting with your application. For each 

section, specify in Column 2 the attachments you are enclosing. Note that not all applicants are required to complete all 

sections or tables.

Column 1 Column 2

 Section 1  w/attachments (e.g., responses for additional outfalls) 

 Section 2  w/attachments 

 Section 3  w/attachments 

 Section 4  w/line drawing  w/additional attachments 

 Section 5  w/attachments 

 Section 6  w/attachments 

 Section 7 

 w/Table A waiver 

request or approval  Table A 

 Table B  Table C 

 Table D  Table E 

 w/other attachments 

 Section 8  w/technical evaluations and related attachments 

 Section 9  w/optional 

information 

 Section 10 

10.2 I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in 

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

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

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

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

possibility of fine and imprisonment for knowing violations. 

Name (first and last) Official Title 

Signature Date Signed 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE A. CONVENTIONAL AND NON-CONVENTIONAL PARAMETER ESTIMATES (40 CFR 122.21(k)(5)(i))1 

Pollutant 

Waiver 

Requested 

(if applicable) 

Units 

Effluent Data 

Maximum Daily 

Discharge 

(required)

Average Daily 

Discharge 

(if available)

Source of Information 

(Use codes in Instructions.) 

 Check here if you have applied to your NPDES authority for a waiver for all of the pollutants listed on this table for the noted outfall. 1. Biochemical Oxygen Demand (BOD5)  Concentration 

Mass 

2. Chemical Oxygen Demand (COD)  Concentration 

Mass 

3. Total Organic Carbon (TOC)  Concentration 

Mass 

4. Total Suspended Solids (TSS)  Concentration 

Mass 

5. Ammonia (as N) 

Concentration 

Mass 

6. Flow  Rate 7. 

Temperature (winter)  °C °C 

Temperature (summer)  °C °C 

8. 

pH (minimum)  Standard Units s.u. 

pH (maximum)  Standard Units s.u. 

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

required under 40 CFR chapter I, subchapter N or

For 

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

Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE B. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(k)(5)(ii))1

Pollutant 

Presence or Absence 

(check one) 

Estimated Data for Pollutants Expected to be Present or Limited by 

(Provide both concentration and mass estimates for each pollutant.)

Believed 

Present 

Believed 

Absent 

Effluent 

Units 

Maximum Daily 

Discharge 

(required) 

Average Daily 

Discharge 

(if available) 

Source of Informatio

(Use codes in Instructions

1. Bromide (24959-67-9)   Concentration 

Mass 

2. Chlorine, Total Residual   Concentration 

Mass 

3. Color   Concentration 

Mass 

4. Fecal Coliform   Concentration 

Mass 

5. Fluoride (16984-48-8)   Concentration 

Mass 

6. Nitrate-Nitrite   Concentration 

Mass 

7. Nitrogen, Total Organic (as N)   Concentration 

Mass 

8. Oil and Grease   Concentration 

Mass 

9. Phosphorus (as P), Total (7723-14-0)   Concentration 

Mass 

10. Sulfate (as SO4) 

(14808-79-8)   Concentration 

Mass 

11. Sulfide (as S)   Concentration 

For 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE B. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(k)(5)(ii))1

Pollutant 

Presence or Absence 

(check one) 

Estimated Data for Pollutants Expected to be Present or Limited by 

(Provide both concentration and mass estimates for each pollutant.)

Believed 

Present 

Believed 

Absent 

Effluent 

Units 

Maximum Daily 

Discharge 

(required) 

Average Daily 

Discharge 

(if available) 

Source of Informatio

(Use codes in Instructions

12. Sulfite (as SO3) (14265-45-3)   Concentration 

Mass 

13. Surfactants   Concentration 

Mass 

14. Aluminum, Total (7429-90-5)   Concentration 

Mass 

15. Barium, Total (7440-39-3)   Concentration 

Mass 

16. Boron, Total (7440-42-8)   Concentration 

Mass 

17. Cobalt, Total (7440-48-4)   Concentration 

Mass 

18. Iron, Total (7439-89-6)   Concentration 

Mass 

19. Magnesium, Total (7439-95-4)   Concentration 

Mass 

20. Molybdenum, Total (7439-98-7)   Concentration 

Mass 

21. Manganese, Total (7439-96-5)   Concentration 

Mass 

22. Tin, Total (7440-31-5)   Concentration 

For 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE B. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(k)(5)(ii))1

Pollutant 

Presence or Absence 

(check one) 

Estimated Data for Pollutants Expected to be Present or Limited by 

(Provide both concentration and mass estimates for each pollutant.)

Believed 

Present 

Believed 

Absent 

Effluent 

Units 

Maximum Daily 

Discharge 

(required) 

Average Daily 

Discharge 

(if available) 

Source of Informatio

(Use codes in Instructions

23. Titanium, Total (7440-32-6)   Concentration 

Mass 

24. Radioactivity 

24.1 Alpha, Total   Concentration 

Mass 

24.2 Beta, Total   Concentration 

Mass 

24.3. Radium, Total   Concentration 

Mass 

24.4 Radium 226, Total   Concentration 

Mass 

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

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

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms

– Not for Implementation

TABLE C. TOXIC METALS, TOTAL CYANIDE, AND TOTAL PHENOLS (40 CFR 122.21(k)(5)(iii)(A))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Present in Disch

(Provide both concentration and mass estimates for each pollutant.)

Believed 

Present 

Believed 

Absent 

Effluent 

Units 

Maximum 

Daily 

Discharge 

(required)

Average 

Daily 

Discharge 

(if available)

Source of Information 

(Use codes in Instructions.)

 Check (

) here if you believe all pollutants listed to be absent from the discharge. You need not complete Table C for the noted outfall unless you 

1. Antimony, Total 

(7440-36-0) 



 Concentration 

 

Mass 

2. Arsenic, Total 

(7440-38-2) 



 Concentration 

 

Mass 

3. Beryllium, Total 

(7440-41-7) 



 Concentration 

 

Mass 

4. Cadmium, Total 

(7440-43-9) 



 Concentration 

 

Mass 

5. Chromium, Total 

(7440-47-3) 



 Concentration 

 

Mass 

6. Copper, Total 

(7440-50-8) 



 Concentration 

 

Mass 

7. Lead, Total 

(7439-92-1) 



 Concentration 

 

Mass 

8. Mercury, Total 

(7439-97-6) 



 Concentration 

 

Mass 

9. Nickel, Total 

(7440-02-0) 



 Concentration 

 

Mass 

10. Selenium, Total 

(7782-49-2) 



 Concentration 

 

Mass 

11. Silver, Total 

(7440-22-4) 



 Concentration 

 

Mass 

12. Thallium, Total 

(7440-28-0) 



 Concentration 

 

Mass 

13. Zinc, Total 

(7440-66-6) 



 Concentration 

 

Mass 

14. Cyanide, Total 

(57-12-5) 



 Concentration 

 

Mass 

15. Phenols, Total 



 Concentration 

 

Mass 

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

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

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

 Check () here if all pollutants listed in Table D are expected to be absent from your facility’s discharge.  Check () here if the facility believes it is exempt from Table D reporting requirements because it is a qualified small business. See the Instructio

of materials you must attach to the application.

Note: If you check either of the above boxes, you do not need to complete Table D for the noted outfall unless you have quantitative data available. 1. Organic Toxic Pollutants (GC/MS Fraction—Volatile Compounds)1.1 Acrolein 

(107-02-8)   Concentration 

Mass 

1.2 Acrylonitrile 

(107-13-1)   Concentration 

Mass 

1.3 Benzene 

(71-43-2)   Concentration 

Mass 

1.4 Bromoform 

(75-25-2)   Concentration 

Mass 

1.5 Carbon Tetrachloride 

(56-23-5)   Concentration 

Mass 

1.6 Chlorobenzene 

(108-90-7)   Concentration 

Mass 

1.7 Chlorodibromomethane 

(124-48-1)   Concentration 

Mass 

1.8 Chloroethane 

(75-00-3)   Concentration 

Mass 

1.9 2-Chloroethylvinyl Ether 

(110-75-8)   Concentration 

Mass 

1.10 Chloroform (67-66-3)   Concentration 

Mass 

1.11 Dichlorobromomethane 

(75-27-4)   Concentration 

For 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

1.12 1,1-Dichloroethane 

(75-34-3)   Concentration 

Mass 

1.13 1,2-Dichloroethane 

(107-06-2)   Concentration 

Mass 

1.14 1,1-Dichloroethylene 

(75-35-4)   Concentration 

Mass 

1.15 1,2-Dichloropropane 

(78-87-5)   Concentration 

Mass 

1.16 1,3-Dichloropropylene 

(542-75-6)   Concentration 

Mass 

1.17 Ethylbenzene 

(100-41-4)   Concentration 

Mass 

1.18 Methyl Bromide 

(74-83-9)   Concentration 

Mass 

1.19 Methyl Chloride 

(74-87-3)   Concentration 

Mass 

1.20 Methylene Chloride 

(75-09-2)   Concentration 

Mass 

1.21 1,1,2,2-Tetrachloroethane 

(79-34-5)   Concentration 

Mass 

1.22 Tetrachloroethylene 

(127-18-4)   Concentration 

Mass 

1.23 Toluene 

(108-88-3)   Concentration 

Mass 

1.24 1,2-Trans-Dichloroethylene 

(156-60-5)   Concentration 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

1.25 1,1,1-Trichloroethane 

(71-55-6)   Concentration 

Mass 

1.26 1,1,2-Trichloroethane 

(79-00-5)   Concentration 

Mass 

1.27 Trichloroethylene 

(79-01-6)   Concentration 

Mass 

1.28 Vinyl Chloride 

(75-01-4)   Concentration 

Mass 

2. Organic Toxic Pollutants (GC/MS Fraction—Acid Compounds)2.1 2-Chlorophenol 

(95-57-8)   Concentration 

Mass 

2.2 2,4-Dichlorophenol 

(120-83-2)   Concentration 

Mass 

2.3 2,4-Dimethylphenol 

(105-67-9)   Concentration 

Mass 

2.4 4,6-Dinitro-O-Cresol 

(534-52-1)   Concentration 

Mass 

2.5 2,4-Dinitrophenol 

(51-28-5)   Concentration 

Mass 

2.6 2-Nitrophenol 

(88-75-5)   Concentration 

Mass 

2.7 4-Nitrophenol 

(100-02-7)   Concentration 

Mass 

2.8 p-Chloro-m-Cresol 

(59-50-7)   Concentration 

Mass 

2.9 Pentachlorophenol 

(87-86-5)   Concentration 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

2.10 Phenol 

(108-95-2)   Concentration 

Mass 

2.11 2,4,6-Trichlorophenol 

(88-05-2)   Concentration 

Mass 

3. Organic Toxic Pollutants (GC/MS Fraction—Base /Neutral Compounds) 3.1 Acenaphthene 

(83-32-9)   Concentration 

Mass 

3.2 Acenaphtylene 

(208-96-8)   Concentration 

Mass 

3.3 Anthracene 

(120-12-7)   Concentration 

Mass 

3.4 Benzidine 

(92-87-5)   Concentration 

Mass 

3.5 Benzo (a) Anthracene 

(56-55-3)   Concentration 

Mass 

3.6 Benzo (a) Pyrene 

(50-32-8)   Concentration 

Mass 

3.7 3,4-Benzofluoranthene 

(205-99-2)   Concentration 

Mass 

3.8 Benzo (ghi) Perylene 

(191-24-2)   Concentration 

Mass 

3.9 Benzo (k) Fluoranthene 

(207-08-9)   Concentration 

Mass 

3.10 Bis (2-Chloroethoxy) Methane 

(111-91-1)   Concentration 

Mass 

3.11 Bis (2-Chloroethyl) Ether 

(111-44-4)   Concentration 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

3.12 Bis (2-Chloroisopropyl) Ether 

(102-80-1)   Concentration 

Mass 

3.13 Bis (2-Ethylhexyl) Phthalate 

(117-81-7)   Concentration 

Mass 

3.14 4-Bromophenyl Phenyl Ether 

(101-55-3)   Concentration 

Mass 

3.15 Butyl Benzyl Phthalate 

(85-68-7)   Concentration 

Mass 

3.16 2-Chloronaphthalene 

(91-58-7)   Concentration 

Mass 

3.17 4-Chlorophenyl Phenyl Ether 

(7005-72-3)   Concentration 

Mass 

3.18 Chrysene 

(218-01-9)   Concentration 

Mass 

3.19 Dibenzo (a,h) Anthracene 

(53-70-3)   Concentration 

Mass 

3.20 1,2-Dichlorobenzene 

(95-50-1)   Concentration 

Mass 

3.21 1,3-Dichlorobenzene 

(541-73-1)   Concentration 

Mass 

3.22 1,4-Dichlorobenzene 

(106-46-7)   Concentration 

Mass 

3.23 3,3-Dichlorobenzidine 

(91-94-1)   Concentration 

Mass 

3.24 Diethyl Phthalate 

(84-66-2)   Concentration 

For 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

3.25 Dimethyl Phthalate 

(131-11-3)   Concentration 

Mass 

3.26 Di-N-Butyl Phthalate 

(84-74-2)   Concentration 

Mass 

3.27 2,4-Dinitrotoluene 

(121-14-2)   Concentration 

Mass 

3.28 2,6-Dinitrotoluene 

(606-20-2)   Concentration 

Mass 

3.29 Di-N-Octyl Phthalate 

(117-84-0)   Concentration 

Mass 

3.30 1,2-Diphenylhydrazine 

(as Azobenzene) (122-66-7)   Concentration 

Mass 

3.31 Fluoranthene 

(206-44-0)   Concentration 

Mass 

3.32 Fluorene 

(86-73-7)   Concentration 

Mass 

3.33 Hexachlorobenzene 

(118-74-1)   Concentration 

Mass 

3.34 Hexachlorobutadiene 

(87-68-3)   Concentration 

Mass 

3.35 Hexachlorocyclopentadiene 

(77-47-4)   Concentration 

Mass 

3.36 Hexachloroethane 

(67-72-1)   Concentration 

Mass 

3.37. Indeno (1,2,3-cd) Pyrene 

(193-39-5)   Concentration 

For 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

3.38 Isophorone 

(78-59-1)   Concentration 

Mass 

3.39 Naphthalene 

(91-20-3)   Concentration 

Mass 

3.40 Nitrobenzene 

(98-95-3)   Concentration 

Mass 

3.41 N-Nitrosodimethylamine 

(62-75-9)   Concentration 

Mass 

3.42 N-Nitrosodi-N-Propylamine 

(621-64-7)   Concentration 

Mass 

3.43 N-Nitrosodiphenylamine 

(86-30-6)   Concentration 

Mass 

3.44 Phenanthrene 

(85-01-8)   Concentration 

Mass 

3.45 Pyrene 

(129-00-0)   Concentration 

Mass 

3.46 1,2,4-Trichlorobenzene 

(120-82-1)   Concentration 

Mass 

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

4.1. Aldrin 

(309-00-2)   Concentration 

Mass 

4.2 α-BHC 

(319-84-6)   Concentration 

Mass 

4.3 β-BHC 

(319-85-7)   Concentration 

Mass 

4.4 γ-BHC 

(58-89-9)   Concentration 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

4.5 δ-BHC 

(319-86-8)   Concentration 

Mass 

4.6 Chlordane 

(57-74-9)   Concentration 

Mass 

4.7 4,4’-DDT 

(50-29-3)   Concentration 

Mass 

4.8 4,4’-DDE 

(72-55-9)   Concentration 

Mass 

4.9 4,4’-DDD 

(72-54-8)   Concentration 

Mass 

4.10 Dieldrin 

(60-57-1)   Concentration 

Mass 

4.11 α-Enosulfan 

(115-29-7)   Concentration 

Mass 

4.12 β-Endosulfan 

(115-29-7)   Concentration 

Mass 

4.13 Endosulfan Sulfate 

(1031-07-8)   Concentration 

Mass 

4.14 Endrin 

(72-20-8)   Concentration 

Mass 

4.15 Endrin Aldehyde 

(7421-93-4)   Concentration 

Mass 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE D. ORGANIC TOXIC POLLUTANTS (Gas Chromatography/Mass Spectrometry or GC/MS Fractions) (40 CFR 122.21(k)(5)(iii)(B))1 

Pollutant

(CAS Number, if available) 

Presence or Absence 

(check one)

Estimated Data for Pollutants Expected to be Presen

(Provide both concentration and mass estimates for each p

Believed 

Present 

Believed 

Absent Units 

Effluent 

Maximum 

Daily 

Discharge 

Average 

Daily 

Discharge 

Source 

Informat

(Use codes in Ins

4.16 Heptachlor 

(76-44-8)   Concentration 

Mass 

4.17 Heptachlor Epoxide 

(1024-57-3)   Concentration 

Mass 

4.18 PCB-1242 

(53469-21-9)   Concentration 

Mass 

4.19 PCB-1254 

(11097-69-1)   Concentration 

Mass 

4.20 PCB-1221 

(11104-28-2)   Concentration 

Mass 

4.21 PCB-1232 

(11141-16-5)   Concentration 

Mass 

4.22 PCB-1248 

(12672-29-6)   Concentration 

Mass 

4.23 PCB-1260 

(11096-82-5)   Concentration 

Mass 

4.24 PCB-1016 

(12674-11-2)   Concentration 

Mass 

4.25 Toxaphene 

(8001-35-2)   Concentration 

Mass 

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

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

For Comment Only
Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

This page intentionally left blank.

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

1. Asbestos  2. Acetaldehyde  3. Allyl alcohol  4. Allyl chloride  5. Amyl acetate  6. Aniline  7. Benzonitrile  8. Benzyl chloride  9. Butyl acetate  

10. Butylamine  11. Captan  12. Carbaryl  13. Carbofuran  14. Carbon disulfide  15. Chlorpyrifos  16. Coumaphos  17. Cresol  18. Crotonaldehyde  19. Cyclohexane 

For 

 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

20. 2,4-D (2,4-Dichlorophenoxyacetic acid)  21. Diazinon  22. Dicamba  23. Dichlobenil  24. Dichlone  25. 2,2-Dichloropropionic acid  26. Dichlorvos  27. Diethyl amine  28. Dimethyl amine  29. Dintrobenzene  30. Diquat  31. Disulfoton  32. Diuron  33. Epichlorohydrin  34. Ethion  35. Ethylene diamine  36. Ethylene dibromide  37. Formaldehyde  38. Furfural 

For 

 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

39. Guthion  40. Isoprene  41. Isopropanolamine  42. Kelthane  43. Kepone  44. Malathion  45. Mercaptodimethur  46. Methoxychlor  47. Methyl mercaptan  48. Methyl methacrylate  49. Methyl parathion  50. Mevinphos  51. Mexacarbate  52. Monoethyl amine  53. Monomethyl amine  54. Naled  55. Napthenic acid  56. Nitrotoluene  57. Parathion 

For 

 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

58. Phenolsulfonate  59. Phosgene  60. Propargite  61. Propylene oxide  62. Pyrethrins  63. Quinoline  64. Resorcinol  65. Strontium  66. Strychnine  67. Styrene  68. 2,4,5-T (2,4,5-Trichlorophenoxyacetic acid)  69. TDE (Tetrachlorodiphenyl ethane)  70. 2,4,5-TP [2-(2,4,5-Trichlorophenoxy) propanoic acid]  71. Trichlorofon  72. Triethanolamine  73. Triethylamine  

74. Trimethylamine  75. Uranium  76. Vanadium 

For 

 

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

EPA Identification Number Facility Name Outfall Number 

Contains Nonbinding Recommendations

Draft Application Forms – Not for Implementation

TABLE E. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(k)(5)(v))1

Pollutant 

Presence or Absence 

(check one) Reason Pollutant Believed Present in Discharge 

Believed 

Present 

Believed 

Absent 

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

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

For Comment Only