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Indiana Dept. of Environmental Management Office of Water Quality - Permits Section 100 N. Senate Avenue Indianapolis, IN 46204 Phone: (317) 232-8670 or Toll Free: 1-800-451-6027 (Indiana residents only) http://www.in.gov/idem/water/publications/appsforms.html

WATER TREATMENT ADDITIVES GREAT LAKES BASIN DISCHARGERS
State Form 53904 (1-09) 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. · The information required by this form must be submitted or every additive that will be utilized by the applicant. INTR
All dischargers are required to disclose information on the water treatment additives in use or proposed for use in accordance with 327 IAC 5-2-9. Dischargers must demonstrate that such additives will not be harmful to aquatic life. 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. The information required by this form must be submitted for each additive in use or proposed for use. 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 bio-monitoring of the effluent for the affected outfall(s) may be required. Please provide the following information for each additive. Discharges are required to disclose information on the water treatment additives in use and to demonstrate that such additives will not be harmful to human health or aquatic life. The following calculations are to be performed on any chemical treatment products ultimately discharged to Water of the State. This worksheet must be completed separately for each chemical treatment product in use. This worksheet is to be returned with all appropriate data entered into the designated areas with calculations performed as indicated. I. Facility Name: ____________________________________________ Outfall Number: _____________

NPDES Permit Number: IN County: ___________________________________________________ Receiving Stream Q7,10

(cfs) X 0.646 =

(MGD)

(The information above may be provided from the permit briefing memo or fact sheet. If you are unable to find this information, please contact the Industrial NPDES Permits Section at 317/232-8706.) What is the Average Daily Discharge (A.D.D.) volume of the final discharge point to the receiving water body? A.D.D. = (in M.G.D.)

Please calculate the In-stream Water Waste Concentration (IWC in percent) of this discharge using the data entered above. IWC = (A.D.D.) X 100 = (1/2 X Q7,10)(0.646) + (A.D.D) ( ( ) X 100 MGD) + ( = ) %

This value (IWC) represents the waste concentration to the receiving water during low flow conditions. II. What is the name of the whole product chemical treatment proposed for use in the discharge identified in Part I? _________________________________________________________________________________________ Check one: Use: New Chemical Treatment Boiler -------------------Replaced Chemical Treatment Water/Waste ----------------------

Cooling ------------------

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Please list the ingredients and percent composition as shown on the MSDS: ___________________________________________ _____________% ___________________________________________ _____________% ___________________________________________ _____________%

Name any ingredient that may be present and may cause toxicity at the proposed Outfall: Chemical Name if known discharge concentration of the ingredient mg/l ,

What feed or dosage rate (D.R.) is used in this application? The units must be converted to maximum grams of whole product used in a 24 hour period. D.R.= grams/24 hour period

Please note, fluid ounces (a volume) must be converted to grams (a mass). The formula for this conversion is: Grams of product = fluid oz. of product x 1 gal. water x 8.34 lbs. x specific gravity of product x 453.59 g. 128 fl. oz. 1 gal. water 1 lb. Estimate total volume of the water handling system between entry of the product and NPDES discharge point: Volume = Total System Volume million gallons million gallons Average Cycle per Blowdown __________ hours

Retention time (lagoons, holding ponds, internal Outfall, internal ditch)

What is the pH of the handling system prior to product addition? In unknown, enter N/A._______________ Outfall Application: Dosage Rate mg/l Blowdown Rate (BD) MGD

Provide additional information which reduces the final concentration of the product at the permitted Outfall: Internal system demand , Volatization , Chemical Reaction ________________

What is the decay rate (D.K.) of the product? If unknown, assume no decay (D.K.=0) and proceed to asterisk (*). The degradation must be stated at pH level within 1/2 pH standard unit within handling system. Enter the half life (Half Life is the time required for the initial product to degrade to half of its original concentration). Please provide copies of the sources of this data. H.L. = ________________ Days The decay rate is equal to 1 X 0.69 = H.L. =Decay Rate (D.K.)

Calculate degradation factor (D.F.). This is the first order loss coefficient. *D.F. = A.D.D. + (D.K.) = (Volume) (MGD) + ( )=

Calculate Steady State Discharge Concentration: Discharge Conc. = (D.R.) = (D.F.)(Volume)(3785) ( (
2

) )( ) (3785)

=

mg/l

If different than Steady State Discharge then, Calculate (provide bases for calculation on a separate sheet) and Show Final Product Concentration: Product Concentration at the Outfall Calculate concentration of product during low flow conditions. (Receiving Water Concentration) (Discharge Conc.) x (IWC%) = 100 III. ( )x( 100 )= mg/l (Receiving Water Concentration) mg/l

Indiana Water Quality Standards Requirements List all LC50 data for the whole product (see 327 IAC 2-1.5-12). Indiana Water Quality Standards require acute toxicity data for at least one of the following three genera in the family Daphnidae: Ceriodaphina sp., Daphnia sp., or Simocephalus sp. If available, also list other organisms listed. Examples have been provided below. Provide copies of the sources of this data. Organism Daphnidae Rainbow Trout Bluegill or Channel Catfish Phylum Chordata (Fish or Amphibian) (i) Benthic Crustacean (ii) Insect (iii) Rotifer, Annelida, Mollusca (iv) Other (v) Test Duration (hours) 48 hours 96 hours 96 hours 96 hours 48 to 96 hours 48 hours 48 to 96 hours 48 to 96 hours ______________ ______________ ______________ ______________ ______________ LC50(mg/l)

Examples: (i) Phylum Chordata (ii) Benthic crustacean Vargula hilgendorfii Cymodoce coronata Caprella californica crayfish Order ephemeroptera odonoata plecoptera trichoptera diptera Lungfish, frog, salamander, toad, etc. Sea Firefly Marine Pill Bug Skeleton shrimp Crawdad mayfly, dragonfly, damselfly, stonefly, caddisfly, mosquito, midge No examples Segmented Worms and Leeches Snails, Slugs, and Bivalves

(iii) Insect

(iv) Rotifera Annelida Mollusca

(v) Other is specified in 327 IAC 2-1.5-11 (d)(2)(A) as "a family in any order of insect or any phylum not already represented."

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Choose the lowest LC50 listed above: A. Enter the LC50: mg/liter B. Enter the Chronic Value: mg/liter

For Comparison of Water Quality Criteria with Discharge Concentration of Water Treatment Additive: Determination of Secondary Acute Value (SAV): 1. ALL FACILITIES If all eight (8) minimum data requirements for calculating an FAV using Tier I (see 327 IAC 2-1.511(d)(2)(A)) are not met, a secondary acute value (SAV) shall be calculated using the lowest LC50 value available for at least one of the following: Ceriodaphinia sp., Daphnia sp., or Simocephalus sp. The lowest LC50 is divided by an adjustment factor, which corresponds to the number of satisfied data requirements listed in 327 IAC 2-1.5-11(d)(2)(A). SAV = Lowest LC50 Listed Above = _____________________mg/liter Adjustment Factor Number of Minimum Date Requirements Satisfied 1 2 3 4 5 6 7 Adjustment Factor 21.9 13.0 8.0 7.0 6.1 5.2 4.3

** To meet Indiana Water quality standards at the Point of discharge, 327 IAC 2-1.5-12, the Steady State Discharge Concentration or the Final Product Concentration of the proposed chemical treatment additive shall not exceed the calculated SAV. Determination of Secondary Chronic Value (SCV): 2. FACILITIES WHICH HAVE A DILUTION FLOW OF LESS THAN 400:1 (Q7,10/Qe) If the chronic value is not available then, Secondary Chronic Value (SCV)= SAV 18 = mg/liter

** To meet Indiana Water Quality Standards 327 IAC 2-1.5-12, the Receiving Water Concentration (calculated in Part II) shall not exceed the calculated SCV. 3. Choose the appropriate Water Quality Criterion and the Water Treatment Additive Concentration from calculations immediately above and place in this blank:

a.

Apply Acute Criterion for all Dischargers From Part II enter the concentration of the product at the Outfall: Discharge Concentration= SAV(Secondary Acute Value)= mg/liter mg/liter

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b.

Apply Chronic Criterion for Dilution Flow <400:1 From Part II enter the receiving water concentration: Receiving Water Concentration= SCV(Secondary Chronic Value)= mg/liter mg/liter

IV.

Analysis. 1. If the Discharge Concentration (part II) is greater than the SAV(Secondary Acute Value), then this chemical treatment additive is unacceptable for use. If the Receiving Water Concentration (part II) is greater than the calculated Secondary Chronic Value (SCV), then this chemical treatment additive is unacceptable for use. Additional product characteristics information such as biodegradation data, partition coefficients, octanol water partition coefficients, and/or other information available to ensure that the concentration of the product does not produce acute or chronic effects on aquatic organisms may be submitted separately.

2.

3.

V.

In addition, list measures in place to ensure that excessive levels of water treatment chemicals are not used and subsequently discharged through Outfalls: _______________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

This information will be reviewed by IDEM to determine if all of the information necessary to properly characterize the water treatment additive and its potential toxicity. If the initial information is not sufficient to allow for this characterization, 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 _________________________________________ Title _________________________________________ Date Signed (mm/dd/yyyy)

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