MUNICIPAL STREAMLINED MERCURY VARIANCE (SMV) APPLICATION State Form 52112 (5-05) Approved by State Board of Accounts, 2005 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Indiana Department of Environmental Management Office of Water Quality – Mail Code 65-42 NPDES Permits Branch 100 North Senate Avenue Indianapolis, Indiana 46204-2251 PART ONE: General Information Name of Facility Facility Address City or Town State ZIP Code County National Pollutant Discharge Elimination System (NPDES) Permit No.: Owner or Person in Responsible Charge (i.e., Town Board President/Mayor) Title Address City or Town State ZIP Code Name of Primary Contact Person Address City or Town State ZIP code Telephone No. E-mail Address (if available) NPDES Outfall(s) Affected by Streamlined Mercury Variance Request: Receiving Stream(s) Affected by Streamlined Mercury Variance Request: Facility Design Flow: Population Served: Number of Significant Industrial Users (as defined in 327 IAC 5-17-23): SIGNATURE BLOCK This application must be signed by a person in responsible charge (see 327 IAC 5-2-22) 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 Title Signature Date Signed (month, day, year) Return the completed SMV application package (Parts I - V) and $50 application fee (see IC 13-18-20-12(a)(4)) to the mailing address listed above. American LegalNet, Inc. www.FormsWorkflow.com PART TWO – POLLUTANT MINIMIZATION PROGRAM PLAN (PMPP) INVENTORY/IDENTIFICATION A. Provide a preliminary inventory of potential uses and sources of mercury in all buildings and departments, as well as a preliminary identification of known mercury-bearing equipment, wastestreams, and mercury storage sites. The following checklist* includes many of the chemicals, equipment, locations, etc. where mercury may be present at your site. For the purpose of satisfying the requirements of this section, you may submit the completed checklist as a preliminary inventory/identification. While the checklist is intended to facilitate the inventory/identification process, it should not be considered as all-inclusive for purposes of establishing a complete inventory. (see 327 IAC 5-3.5-9(a)(1) and 327 IAC 5-3.5-9(a)(2)) LABORATORY EQUIPMENT Manometers Ion exchange cartridges for lab water purification system Barometers Hanging mercury drop electrodes for polarographic analyzers Thermometers Mercury Hallow Cathode lamp for AA analysis LABORATORY CHEMICALS COD analysis reagent (mercuric sulfate) Mercury or mercurous chloride TKN and TP analysis digestion reagents Mercury iodide Nessler reagent Mercury nitrate Mercury analytical standards Mercury (II) oxide Gas chromatograph sample interferences (elemental mercury) Mercury (II) sulfate Sodium hypochlorite (Clorox) Merthiolate BULK CHEMICALS Phosphorus removal chemicals Chlorine Dechlorination chemicals Sodium hypochlorite Sludge thickening polymers Sulfuric acid Potassium hydroxide Nitric acid Sodium hydroxide Ferric or ferrous chloride Sodium chloride Pickling liquor (for phosphorus removal) PROCESS CONTROL AND MEASURING EQUIPMENT Accustats Ring balances Barometers Shunt trips Counterweights Steam flow meters Stokes gauges Elemental mercury for refilling mercury-containing equipment Switches and relays: Flow meters Gas regulators and meters Displacement plunger relays Mercoid control switches Gyroscopes Hydrometers with thermometers Level and rotation sensors Manometers, pressure gauges and vacuum gauges Mercury-sealed pistons Permeters Pressure-trols Pyrometers Rectifiers Pressure control switches (mounted on bourdon tube or diaphragm) Relay switches Mercury wetted relays Mercury displacement relays (found in motors) Sump pump, bilge pump and other float controls Tilt switches Thermometers (including industrial dial face thermostats with capillary tubes.) Thermostats and thermoregulators Transmitters BUILDINGS DC watt-hour meters Flame sensors (found in the pilot light and burner assembly on gas-fired furnaces, boilers, unit heaters and space heaters) * This checklist was borrowed from the Delta Institute. Municipal Streamlined Mercury Variance Application State Form 52112 (5-05) Hydronic and warm air controls with tilt switches such as: Aquastats Pressurestats Firestats Fan limit controls Pressure/flow controls on air handling units. 2 American LegalNet, Inc. www.FormsWorkflow.com PART TWO (CONTINUED) BUILDINGS (continued) Switches and relays: Fire alarm box switches Silent light switches Relay switches Mercury wetted relays Mercury displacement relays (found in lighting, resistance heating and motors) Sump pump, bilge pump, flow monitor, float switches, and other float controls Tilt switches Phosphorus removal chemicals: Ferric or ferrous chloride Pickling liquor Thermostats BEARINGS AND SEALS Trickling filter Pivot Arm Bearings (mercury bearings/water seals) LAMPS Fluorescent Mercury vapor lamps High-pressure sodium Metal halide Mercury arc Ultraviolet disinfection BATTERIES Mercury-zinc (button) batteries Mercury alkaline batteries Mercury-cadmium batteries Mercury oxide batteries PAINT Old latex-paint (pre-1990) Marine paint FIRST AID/MEDICAL Mercurochrome Thermometers Thimerosal (contained in eye wash) Sphygmomanometers OTHER Fleet vehicles may contain ABS, convenience and trunk lighting Old pesticides, fungicides and herbicides switches and HID headlamps Tree root growth control products Computer monitors COLLECTION SYSTEM Lift station equipment Sewer lines with accumulated mercury Traps with accumulated mercury Other mercury containing equipment Sumps with accumulated mercury Mercury-containing chemicals used and/or stored on-site MERCURY STORAGE SITES Elemental mercury Mercury-containing items collected for disposal B. Provide a plan and schedule for providing a complete inventory initiated under Section A. above. (see 327 IAC 5-3.5-9(a)(1)) The schedule required under this part should be expressed in terms of months from the date of NPDES permit issuance, renewal, or modification that incorporates the approved SMV. It is recommended that the schedule required under this part be developed in conjunction with the other schedules for action required by the SMV application. A complete inventory should include an estimate of quantities (i.e., volume of chemicals used annually, or numbers of mercury containing equipment) for each item identified in Part II.A. Additionally, a complete inventory should include documentation from chemical suppliers and equipment suppliers of the mercury content in your most commonly purchased items. Mercury may not be present in a concentration great enough to appear on an MSDS, yet still contribute to the overall level of mercury in the influent. Municipal Streamlined Mercury Variance Application State Form 52112 (5-05) 3 American LegalNet, Inc. www.FormsWorkflow.com PART TWO (CONTINUED) C. Provide the results of a preliminary evaluation of possible mercury sources in the facility's influent. The preliminary evaluation must include an initial list identifying all potential sources of mercury in the POTW’s influent by name and address. The preliminary evaluation shall take into consideration, at a minimum, the following: (see 327 IAC 5-3.5-9(b)(1)) 1. Medical facilities, for example, the following: a. Hospitals. b. Clinics. c. Nursing homes. d. Veterinary facilities. 2. Dental clinics. 3. Public and private educational laboratories. 4. General industry and all SIU’s. 5. Significant sources of residential and retail contributions of mercury, for example, the following: a. Heating, ventilation, and air conditioning contractors. b. D. Veterinarians. d. 6. Automobile and appliance repair. c. Others specific to the community served. An identification of the responsibilities under P.L.225-2001 (also known as House Enrolled Act 1901 of the 2001 legislative session) for the significant industrial users for the POTW. P.L.225-2001 outlines the restrictions on the sale or supply of mercuryadded novelties, mercury-added products, and mercury commodities, and on the use or purchase of mercury commodities, compounds, or mercury-added instructional equipment and materials by public and non-public schools. In order to satisfy the requirement of this part, include a written statement that attests to the fact that an identification of the responsibilities under P.L.225-2001 has been undertaken. Provide a plan and schedule for completion of the evaluation initiated under Section C. above. A complete evaluation should include a list identifying all confirmed sources of mercury in the POTW’s influent by name and address. The schedule required under this part should be expressed in terms of months from the date of NPDES permit issuance, renewal, or modification that incorporates the approved SMV. It is recommended that the schedule required under this part be developed in conjunction with the other schedules for action required by the SMV application. (see 327 IAC 5-3.5-9(b)(1)) PART THREE - POLLUTANT MINIMIZATION PROGRAM PLAN (PMPP) PLANNED ACTIVITIES A. Provide a list of planned activities to be conducted to eliminate or minimize the release of mercury to waters of the state. The list of planned activities may consider technical and economic feasibility and must include, at a minimum: (see 327 IAC 5-3.5-9(a)(3)) 1. A review of purchasing policies and procedures. 2. Necessary training and awareness for facility staff including an education program. 3. An education program for the public within the service area of the facility. 4. Evaluation of alternatives to the use of any mercury-containing equipment or materials. 5. Other specific activities designed to reduce or eliminate mercury loadings. 6. An identification of the facility's responsibilities under P.L.225-2001 (also known as House Enrolled Act 1901 of the 2001 legislative session). Under P.L.225-2001, a municipality may, in cooperation and with the support of IDEM, implement education programs for the public regarding the reuse and recycling of, or independently implement collection programs for, mercury commodities and mercury-added products. In order to satisfy the requirement of this part, include a written statement that attests to the fact that an identification of the responsibilities under P.L.225-2001 has been undertaken. B. For each planned activity identified under section A. above, include the following: (see 327 IAC 5-3.5-9(a)(4)) 1. The goal to be accomplished. 2. A measure of performance. PART THREE (CONTINUED) Municipal Streamlined Mercury Variance Application State Form 52112 (5-05) 4 American LegalNet, Inc. www.FormsWorkflow.com 3. A schedule for action. The schedule required under this part should be expressed in terms of months from the date of NPDES permit issuance, renewal, or modification that incorporates the approved SMV. It is recommended that the schedule required under this part be developed in conjunction with the other schedules for action required by the SMV application. C. Provide a list of planned activities designed to reduce or eliminate mercury loadings from each sector identified in Part II.C. of the application, including the goal to be accomplished, a measure of performance, and a schedule for action. (see 327 IAC 5-3.5-9(b)(2)) The schedule required under this part should be expressed in terms of months from the date of NPDES permit issuance, renewal, or modification that incorporates the approved SMV. It is recommended that the schedule required under this part be developed in conjunction with the other schedules for action required by the SMV application. An example of planned activities, goals, measures of performance and schedules for action for the sectors identified in Part II.C. is provided in Attachment A. D. Provide an identification of the resources and staff necessary to implement the Pollutant Minimization Program Plan (PMPP). (see 327 IAC 5-3.5-9(a)(6)) The identification should indicate the source and amount of funding available to implement the PMPP, as well as the number and position of employees that will be devoted to PMPP implementation. PART FOUR – MERCURY MONITORING DATA Provide all available influent and effluent mercury data for the two-year period preceding submittal of this application. Additionally, provide any information on mercury in biosolids for the two-year period preceding submittal of this application, if available. The data may be supplied on a separate form, but must include results for each individual sample (including unit of measurement and U.S. EPA method), the date the sample was taken, and the analytical laboratory where the analysis was performed. (see 327 IAC 5-3.5-9(a)(5)) Influent Date (month, day, year) Result ng/l U.S. EPA Method Analytical Laboratory Result ng/l U.S. EPA Method Analytical Laboratory Effluent Date (month, day, year) PART FOUR (CONTINUED) Municipal Streamlined Mercury Variance Application State Form 52112 (5-05) 5 American LegalNet, Inc. www.FormsWorkflow.com Biosolids Date (month, day, year) Result Unit U.S. EPA Method Analytical Laboratory PART FIVE – POLLUTANT MINIMIZATION PROGRAM PLAN (PMPP) ADDITIONAL REQUIREMENTS A. Proof of Public Notice Activities: Provide proof of the public notice activities identified below: (see 327 IAC 5-3.5-9(c)) For the notice of availability required under Section A.1. provide a copy of the notice as it appears in the newspaper. For the posting requirements under Section A.2. attest to that fact that the information was posted as required in a written statement. 1. Publish notice of the availability of the draft pollutant minimization program plan (PMPP) in a daily or weekly newspaper of general circulation throughout the area affected by the discharge. 2. Post a copy of the information required by this section at the following: a. Principal office of the municipality or political subdivision affected by the facility or discharge. b. The United States post office. c. If one is available, the library serving those premises. 3. All notices published under this section shall contain the following information: (see 327 IAC 5-3.5-9(d)) a. The name and address of the applicant that prepared the PMPP. b. A general description of the elements of the PMPP. c. A brief description of the activities or operations that result in the discharge for which an SMV is being requested. d. A brief description of the purpose of this notice and the comment procedures. e. The name of a contact person, a mailing address, an Internet address, if available, and a telephone number where interested persons may obtain additional information and a copy of the PMPP. 4. The applicant shall do the following: (see 327 IAC 5-3.5-9(e)) a. Provide a minimum comment period of thirty (30) days. b. Include a copy of the comments received and the applicant's responses to those comments in the SMV application submitted to the department. B. Annual Reports: Provide a schedule for the submission of the annual reports required under 327 IAC 5-3.5-9(a)(8). Generally, the annual reports should be submitted each year on the anniversary of the effective date of the NPDES permit that incorporates the approved SMV. A proposed schedule with an alternative submittal date is subject to IDEM's approval. The annual reports shall include a description of the facility's progress toward fulfilling each PMPP requirement, mercury monitoring results, and steps taken to implement each planned activity developed under the PMPP. Municipal Streamlined Mercury Variance Application State Form 52112 (5-05) 6 American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT A Sector Planned Activity Goal Measure of Performance Schedule of Action On-site visits Promote BMP implementation Participation 9 months from SMV approval Workshops Education/awareness Participation 6 months from SMV approval Mercury-free where ever practicable Progress, quantity recycled 9 months from SMV approval Mail appropriate BMP literature Education/awareness Date mailed and content 6 months from SMV approval Education/awareness Participation 6 months from SMV approval Promote BMP implementation Participation 6 months from SMV approval Participation Participation 9 months from SMV approval Adherence to ADA’s BMP (voluntary or mandatory) Minimize mercury discharged Adoption/implementation 9 months from SMV approval Mercury recycling (voluntary or mandatory) Minimize mercury discharged Quantity recycled 12 months from SMV approval Adoption of removal equipment meeting ISO standards Adoption/implementation Adoption/implementation 12 months from SMV approval Mail appropriate BMP literature Education/awareness Date mailed and content 6 months from SMV approval Workshops Education/awareness Participation 12 months from SMV approval On-site visits Promote BMP implementation Participation 9 months from SMV approval Mail chemical/equipment literature Education/awareness Date mailed and content 6 months from SMV approval On-site visit during pretreatment inspection Ensure permit compliance Education/awareness Compliance evaluation To coincide with annual pretreatment inspection Application of local limits Significant sources of residential and retail contribution of mercury, for example, the following: • heating, ventilation, and air conditioning contractors • automobile and appliance repair • veterinarians • others specific to the community served 9 months from SMV approval Survey(s) General industry and all SIU’s Date mailed and content On-site visits Public and private educational laboratories Education/awareness Meetings with dentists Dental clinics Mail AHA BMP literature BMP requirements Medical facilities, including • hospitals • clinics • nursing homes • veterinary facilities Mercury reduction Compliance evaluation To coincide with permit renewal Mail appropriate BMP literature Education/awareness Participation 12 months from SMV approval Workshops Education/awareness Participation 12 months from SMV approval On-site visits Promote BMP implementation Participation 9 months from SMV approval Trade association coordination, where appropriate Increased participation Participation 9 months from SMV approval Survey(s) Participation Participation 9 months from SMV approval Municipal Streamlined Mercury Variance Application State Form 52112 (5-05) 7 American LegalNet, Inc. www.FormsWorkflow.com