2E APPLICATION FOR APPROVAL TO USE WATER TREATMENT ADDITIVES State Form 50000 (R2 / 10-04) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be submitted to the IDEM, Office of Water Quality, Industrial NPDES Permits Section when applying for a new or renewal NPDES permit or permit modification. Indiana Dept. of Environmental Management Office of Water Quality - Permits Section 100 N. Senate Avenue Indianapolis, IN 46204 Phone: (317) 234-0864 or 1-800-451-6027 (Indiana Residents Only) http://www.state.in.us/idem/owm/appforms.html The information required by this form must be submitted for each additive submitted for review. INTRODUCTION All dischargers are required to disclose information on the water treatment additives in use and to demonstrate that such additives will not be harmful to aquatic life. To assure that all discharges from treatment systems using water treatment chemicals meet Indiana Water Quality Standards, when applying for a new or renewal NPDES permit or permit modification. During the preparation of the NPDES permit or modification, this information may be used to establish permit limitations which comply with all Indiana Water Quality Standards. Additionally, if a permittee changes water treatment additives during the term of their NPDES permit, the following information must be submitted to the Industrial NPDES Permits Section, and approval of the change must be received prior to use of the new product(s). The information required by this form must be submitted for each additive submitted for review. Some of this information may come from the Material Safety Data Sheet (MSDS) for the additive and should be included with this application. It should also be noted that biomonitoring of the effluent for the affected outfall(s) may be required. Please provide the following information for each additive. The following information must be submitted to the IDEM, Office of Water Quality, Industrial NPDES Permits Section PART A: GENERAL INFORMATION 1. Name of authorized official (first, last): 2. Name of facility: 3. Mailing address: City: State: ZIP Code: CONTACT PERSON 4. Name of primary contact person (first, last): 5. Phone number: 6. E-mail address (optional): FACILITY 7. Facility address: City: 8. State: ZIP Code: Phone number: 9. County: E-mail address (optional): 10. NPDES Permit Number(if facility has an existing permit): 1 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Water Quality NPDES -Application for Approval to Use Water Treatment Additives State Form 50000 (R2 / 10-04) PART B: ADDITIVE DETAILS 11. Name of water treatment additive New Previously Approved 12. Chemical composition of the water treatment additive1 : 13. What is the feed or dosage rate in grams/24 hr. period. (This may be provided in fluid ounces): 14. If more than one Outfall is covered by this permit, which Outfall does the use of this water treatment additive affect? A separate form is required per additive for each affected outfall: 15. Name any ingredient(s) that may be present and may cause toxicity at the proposed Outfall. If known, provide the discharge concentration of the ingredients (mg/I): 16. Provide the location where the additive is put into use2 : 17. Provide the duration of use for the additive (hours per day and days per year): hours/day days/year PART C: ADDITIVE CONCENTRATION 18. Concentration (mg/l) of the water treatment additive used in the treatment system: 19. The concentration (mg/l) of the water treatment additive used in the final discharge (if known): 20. Discharge concentration of the water treatment additive (mg/l): 21. Please explain how the final discharge concentration stated for item # 20 was arrived at 2 : 22. Provide a description and method used to control the use of the water treatment additive. What are the procedures on how to maintain this concentration within the system ?: 1 2 Proprietary information may be submitted separately by the manufacturer or distributor and will be kept confidential. If necessary, this information may be provided on supplementary attachments. 2 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Water Quality NPDES — Application for Approval to Use Water Treatment Additives State Form 50000 (R2 / 10-04) PART D: SYSTEM & DISCHARGE DETAILS 23. Provide the hardness of the discharge water: 24. The temperature of the treatment system using the water treatment additive (specify ºF or ºC): O F O C 25. The Blowdown Rate (MGD) from the treatment system using the water treatment additive: 26. The average flow (MGD) of all waste streams being discharged through the affected Outfall: 27. The pH of the treatment system using the water treatment additive: PART E: CHEMICAL PROPERTIES/TOXICITY DATA For determining safe concentrations of the water treatment additives, the following information should also be submitted or addressed. Submit the supporting documentation (i.e., Material Safety Data Sheets) as attachments to this application. 28. Toxicity (LC50) of the additive3 : 29. Test species 4 : 30. Please explain, or provide attachments to explain, the relation of toxicity to pH: 31. Please explain, or provide attachments to explain the relationship of toxicity to water hardness: 3 As determined by 96-hour flow through bioassays for fish (preferably fathead minnow (Pimephales promelas) or bluegill (Lepomis macrochirus) for warmwater species or rainbow trout (Salmo gairdneri) for coldwater species) and a 48-hour static renewal for invertebrates (preferably of the genera Daphnia or Ceriodaphnia). Testing procedures to determine LC50 values should follow U.S. EPA Guidelines. Static bioassays are acceptable only if the treatment chemical is persistent. The test temperature should be maintained at 20º Celsius (68º Fahrenheit) for coldwater species and at 30º Celsius (86º Fahrenheit) for warmwater species (higher test temperatures are chosen in order to simulate worst case conditions. Lower test temperatures may be used only if the thermal tolerance of the chosen representative aquatic species is below the recommended test temperatures). 4 The test species selected should be characteristic of the more sensitive representative aquatic species in the receiving stream. 3 American LegalNet, Inc. www.FormsWorkflow.com Indiana Department of Environmental Management Office of Water Quality NPDES — Application for Approval to Use Water Treatment Additives State Form 50000 (R2 / 10-04) PART E: CHEMICAL PROPERTIES Product persistence in the environment and N Octanol-Water Partition Coefficient and Bioconcentration Factor (BCF) (if available). 32. Provide the decay rate of the product, if known. This should be stated at a pH level within ½ pH standard unit within the handling system 5. (Please provide copies of the sources of this data as attachments to this application.): 33. Provide any additional information or attach any additional documentation to help in evaluating the use of this water treatment additive: This information will be reviewed and permission to use the water treatment additive may be granted either by letter, permit limitations, or permit modification, if the discharger has supplied the requested product information and toxicity data that will enable IDEM to establish permissible concentrations in each individual case. If the initial information is not sufficient to allow for the establishment of a safe concentration, additional information will be requested. Proprietary information regarding the chemical composition of any water treatment additive will be kept confidential in accordance with the terms of 327 IAC 12.1. Claims of confidentiality must be made at the time of submittal; the information must be properly marked, segregated and secured at the time of submittal; and the person or company requesting confidentiality must provide justification as to why the information meets the criteria for it to be maintained as a trade secret, privileged information or confidential in accordance with 327 IAC 12.1 This application should include the following and must be signed by a person in responsible charge to be valid. This signature attests to the following: “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.” (Printed Name) (Signature) 5 (Title) (Date Signed (mm/dd/yyyy)) The half life is the time required for the initial product to degrade to half of its original concentration. 4 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT IDENTIFICATION OF POTENTIALLY AFFECTED PERSONS Please list here any and all persons whom you have reason to believe have a substantial or proprietary interest in this matter, or could otherwise be considered to be potentially affected under the law. Failure to notify any person who is later determined to be potentially affected could result in voiding our decision on procedural grounds. To ensure conformance with AOPA and to avoid reversal of a decision, please list all such parties. The letter attached to this form will further explain the requirements under the AOPA. Attach additional names and addresses on a separate sheet of paper, as needed. Please indicate below the type of action you are requesting. Name Street City State ZIP Name Street City State ZIP Name Street City State ZIP Name Street City State ZIP Name Street City State ZIP Name Street City State ZIP Name Street City State ZIP Name Street City State ZIP Please complete this form by signing the following statement: I Certify that to the best of my knowledge I have listed all potentially affected parties, as defined by IC 4-21.5. Date Signature Printed Name Facility Name Address Type of Action: (check one) NPDES Permit-327 IAC 5 Land Application Permit-327 IAC 6 Confined Feeding Approval-IC 13-18-10 Return To: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Office of Water Quality, NPDES Permits Section 100 North Senate Avenue Indianapolis, IN 46204 Sewer Ban Waiver Request-327 IAC 4 Operator Certification-327 IAC 4 Pretreatment Permit-327 IAC 5 Construction Permit-327 IAC 3 5 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT REQUEST FOR INFORMATION We request that you fill in the blanks on this form and return it along with your NPDES PERMIT application. The information provided will be helpful in our personal contact with officials of your municipality, industry or other facility in assuring prompt delivery of correspondence, etc. Thank you for your cooperation. I. Current NPDES Permit No. (New applicants will be assigned a number later) II. WASTEWATER TREATMENT FACILITY LOCATION ADDRESS Facility Name: Address: City: Telephone: III. State: ZIP: DISCHARGE MONITORING REPORT (DMR) MAILING ADDRESS (ADDRESS WHERE IDEM IS TO SEND PRE-PRINTED DMRS) Name: Title: Address: City: State: ZIP: Telephone: Cognizant Official (Representative responsible for completing DMR): Title: IV. OWNER ADDRESS Owner Name: Address: City: Telephone: V. Title: State: ZIP: WASTEWATER TREATMENT PLANT OPERATOR/SUPERINTENDENT ADDRESS Operator Name: Address: City: Telephone: Work: Certificate No. State: ZIP: Home: 6 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OWNER/OPERATOR AFFIDAVIT TO DETERMINE THE APPROPRIATE NPDES PERMITTEE(S) 327 IAC 5-2-3(c) requires the operator to apply for and obtain the NPDES permit for the NPDES discharge, unless the operator is an employee of the owner of the facility (in which case it is the owner’s responsibility to apply for and obtain the NPDES permit). This is consistent with the federal regulations at 40 CFR 122.21(b). Additionally, pursuant to 327 IAC 5-2-6(c), the permittee is required to notify IDEM if there is a change in either the ownership or the operation of the wastewater treatment plant. When an NPDES permittee contracts with a private firm to operate its wastewater treatment plant, and the contractual agreement is one in which the private entity is not an employee of the owner, the permit should be issued to the private firm. Some contractual arrangements may have been made without knowledge of this rule requirement, and the contract may not have been adequately set up to reflect the private firm as the sole permittee. Or the private contractor may not want to be the sole permittee. Therefore, in such instances EPA has suggested that the permit be issued to both the owner and to the private contractor, as co-permittees. In order to help us to determine who should be listed on the NPDES permit as the permittee(s), please complete the following information: 1. Facility Name: 2. NPDES Permit No.: 3. Owner’s Name: (individual or legal business name) Owner’s Mailing Address: 4. Operator’s Name: (individual or legal business name) Operator’s Mailing Address: 5. Is the operator an employee of the owner? 6. If the answer to #5 is “No”, is the operator willing to be the sole permittee? YES 7. NO YES NO N/A If the answer to #6 is “No”, the NPDES permit will be issued to both the owner and operator as co-permittees. “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." (Owner’s signature) (Operator’s signature) Please complete this form and return it to IDEM, Office of Water Quality, Municipal NPDES Permits Section 100 North Senate Ave. Indianapolis, IN 46204 7 American LegalNet, Inc. www.FormsWorkflow.com NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) GENERAL INFORMATION FORM (TO BE SUBMITTED WITH FORMS 2C, 2D AND 2E) (Replaces EPA General Form 1) 1. Name of Facility: 2. Facility Contact Name: Adress: City or Town: State: State: ZIP Code: State: Telephone: Work: ZIP Code: ZIP Code: Home: 3. Certified Operator Name: Certification #: Classification: Address: City or Town: Home: Telephone: Work: 4. Facility Mailing Address: Street or P.O. Box: City or Town: 5. Facility Location: Street, Route No. or Other Specific Identifier: 6. Type of Permit Action: New Renewal Modification 7. EPA I.D. Number: 8 American LegalNet, Inc. www.FormsWorkflow.com 8. Does or will this facility (either existing or proposed) include a concentrated animal feeding operation or aquatic animal production facility which results in a discharge to waters of the state? (Form 2B) Yes No Form Attached 9. Is this a facility which currently results in discharges to waters of the state other than described in 8? (Form 2C-Process Wastewater or Form 2E-Nonprocess Wastewater) Yes No Form Attached 10. Is this a proposed facility (other than described in 8) which will result in a discharge to waters of the state? (Form 2D) Yes No Form Attached 11. SIC Codes (4-digit, in order of priority) Specify: First: Second: Third: Fourth: Specify: Specify: Specify: 12. Existing Environmental Permits (Identification #) NPDES (Discharges to Surface Waters): UIC (Underground Injection of Fluids): RCRA (Hazardous Wastes): PSD (Air Emissions from Proposed Sources): Other: Other: Specify: Specify: 13. Nature of Business (Provide a Brief Description) 14. Map Attach to this application a topographic map of the area extending to at least one mile beyond property boundaries. The map must show the outline of the facility, the location of each of its existing and proposed intake and discharge structures, each of its hazardous waste treatment, storage, or disposal facilities, and each well where it injects fluid underground. Include all springs, rivers and other surface water bodies in the map area. 9 American LegalNet, Inc. www.FormsWorkflow.com 15. Signature Block: This application must be signed by a person in responsible charge to be valid. This signature attests to the following: " 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 valuate 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". (Printed Name) (Title) (Signature) (Date Signed) Return Completed Application and Associated Materials to: Indiana Department of Environmental Management Office of Water Quality, NPDES Permits Section 100 North Senate Avenue Indianapolis, Indiana 46204 10 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT INDUSTRIAL NPDES PERMIT APPLICATION REVIEW CHECKLIST Form 2E The outfall number, Lat./Long., and receiving stream. The anticipated discharge date for a new discharger. The type of wastewater and any water treatment additives used. The applicant must provide analytical results for all pollutants listed in Part IV unless they obtain a waiver from us first. A description of any intermittent or seasonal discharge. A description of the wastewater treatment system. Other information that the applicant believes should be brought to the attention of the permit writer. The name, title, phone number, signature and date signed of the person who is filing the application. Additional Information Water Treatment Additives MSDS including aquatic toxicity information (LC50) Zebra Mussel Controls 11 American LegalNet, Inc. www.FormsWorkflow.com Application for Permit to Facilities Which Do Not Discharge Process Wastewater (OWQ Industrial NPDES Application 2E) EPA Identification Number (copy from Item 1 of Form 1) I. RECEIVNG WATERS For this outfall, list the latitude and longitude, and the name of the receiving water. A. OUTFALL 1. DEG. B. LATITUDE 2. MIN. 3. SEC. D. RECEIVING WATER(name) C. LONGITUDE 1. DEG. 2. MIN. 3. SEC. NUMBER II. DISCHARGE DATE (If a new discharger, the date you expect to begin discharging) III.TYPE OF WASTES A. Check the box(es) indicating the general type(s) of wastes discharged. Sanitary Wastes B. Restaurant or Cafeteria Wastes Non-contact Cooling Water Other Non-process Wastewater (Identify) : If any cooling water additives are used, list them here. Briefly describe their composition if this information is available. IV. EFFLUENT CHARACTERISTICS A. Existing Sources – Provide measurements for the parameters listed in the left hand column, unless waived by the permitting authority (see instructions). B. New Dischargers- Provide estimates for the parameters listed in the left-hand column below, unless waived by the permitting authority. Instead of the number of measurements taken, provide the source of estimated value (see instructions). (2) Average Daily Value (last year) (include units) (1) Maximum Daily Value (include units) Pollutant or Parameter Mass Concentration Mass Concentration (3) Number of Measurements Taken (last year) or (4) Source of Estimate (if new discharger) a. Biochemical Oxygen Demand, Carbonaceous Cas No. E10106 b. Escherichia coli (E-coli - units in count/100ml) Cas No. I-1000 Fecal coliform (units in count/100 ml) Cas No. I-1000 Chemical Oxygen Demand (COD) Cas No. E10107 Dissolved Oxygen (DO) Cas No. E-14539 Total Dissolved Solids (TDS) Cas No. E10173 Total Organic Carbon (TOC) Cas No. E-10195 Total Suspended Solids (TSS) Cas No. E10162 Ammonia (as N) Cas No. 7664-41-7 Flow VALUE Temperature (Winter ) (Cent.) Cas No. E14540 C C Temperature (Summer) (Cent.) Cas No. E14540 C C Hardness, Total (as (CaCO3) Cas No. E11778 pH (S.U.) Cas No. E-10139 MINIMUM MAXIMUM * If non-contact cooling water is discharged 12 American LegalNet, Inc. www.FormsWorkflow.com EPA Identification Number (copy from Item 1 of Form 1) Outfall Number V. Except for leaks or spills, will the discharge described in this form be intermittent or seasonal? Yes No If yes, briefly describe the frequency of flow and duration. VI. TREATMENT SYSTEM (Describe briefly any treatment system(s) used or to be used) VII. OTHER INFORMATION (Optional) Use the space below to expand upon any of the above questions or to bring to the attention of the reviewer any other information you feel should be considered in establishing permit limitations. Attach additional sheets, if necessary. VIII. CERTIFICATION “I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.” A. Name & Official Title B. Phone No. (area code & no.) C. Signature D. Date Signed 13 American LegalNet, Inc. www.FormsWorkflow.com