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APPLICATION FOR INDUSTRIAL WASTEWATER PRETREATMENT (IWP) PERMIT
State Form 50271 (R2 / 9-08)

IDEM - Office of Water Quality Attn: Cashier Pretreatment Section
100 N. Senate Avenue Indianapolis, IN 46204 Phone: (317) 232- 8603 or toll-free 1-800-451-6027 (Indiana Residents Only)
http://www.in.gov/idem/water/permits/

Approved by State Board of Accounts, 2008 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
INSTRUCTIONS: · This form must be accompanied by state form 49456. You may find state form 49456 at http://www.in.gov/icpr/webfile/formsdiv/49456.pdf . Both forms must be submitted together. · Unless stated otherwise, all items are to be filled out completely. Your application will not be considered complete unless every question is answered on this form. If an item is not applicable, indicate by noting "NA" to show that you considered the question. · Depending upon the adequacy of the data submitted for determining issuance of a permit, additional information may be required. Please read all questions and attached information prior to completing this application. · You can fill out this form electronically, using the mouse and keyboard. Simply click inside of the first form field to begin, and advance to the next fields using the "tab" key on your keyboard, or by clicking in the fields with your mouse. Print the completed form, and submit it to IDEM, OWQ with any additional documentation in your application packet. · A $50 application fee is required with the submission of this form. Please enclose a check or money order payable to the Indiana Department of Environmental Management with this form and any supporting attachments and documentation, and mail the application package to the address listed in the upper-right side of this page. · This application must be submitted in accordance with 327 IAC 5-21-3, including the time frames thereof.

Type of IWP Permit New Renewal Modification

IWP PERMIT NUMBER

PART A: APPLICANT ADDRESS AND CONTACT(S)
FACILITY/OPERATION

1. Facility name: 2. Mailing address: City: 3. Facility phone number: 5. Address of operation: City:
DESIGNATED FACILITY CONTACT PERSON

County:

State:

ZIP Code:

4. Facility e-mail address (optional):

State:

ZIP Code:

6. Designated contact name (first, last): 8. Mailing address: City: 9. Phone number: State:

7. Title:

ZIP Code:

10. E-mail address (optional):

DESIGNATED SIGNATORY AUTHORITY NOTE: Signatory Authorization is defined in 327 IAC 5-16-5(b)

11. Designated signatory authority name (first, last): 13. Address: City: 14. Phone number: State:

12. Title:

ZIP Code:

15. E-mail address (optional):
(Continued on page 2)

(Account No. and Revenue Code: 2830-433800-100600) Page 1 of 9

Indiana Department of Environmental Management Office of Water Quality

Application for Industrial Wastewater Pretreatment (IWP) Permit 10-04

RECEIVING POTW:

16. Contact Name 18. Address: City: 19. Phone number:
SHIFT INFORMATION

17. Title:

State:

ZIP Code:

20. E-mail address (optional): PART B: OPERATING SCHEDULE

21. 22. 23. 24.

Days of operation (check all that apply): Hours per day of operation: Number of shifts per day: Total number of employees per shift:

Mon.

Tue.

Wed.

Thu.

Fri.

Sat.

Sun.

DURATION OF OPERATION

25. Date that facility began (or will begin) operation (mm/dd/yyyy): 26. Indicate whether the operation is (will be): a. Continuous throughout the year b. Seasonal (check the boxes below corresponding with the months of active production) Jan. Feb. Mar. April May June July Aug. Sept. Oct.
CLOSED-LOOP OPERATIONS

Nov.

Dec.

27. Describe any closed-loop operations:

28. Does this water ever contact the product?

Yes

No Yes* No

29. Does the system ever discharge to the city sewer? *If yes, a. How often? b. How much? c. Is this water pretreated? Yes No

(Continued on page 3)

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Indiana Department of Environmental Management Office of Water Quality

Application for Industrial Wastewater Pretreatment (IWP) Permit 10-04

PART C: PROCESS DESCRIPTION 30. Describe the product(s) manufactured or service(s) provided:

31. Provide a detailed description of the manufacturing process(es) or service activities conducted on premises, especially those processes that involve or generate wastewater (use additional sheets if necessary).

(Continued on page 4)
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Indiana Department of Environmental Management Office of Water Quality

Application for Industrial Wastewater Pretreatment (IWP) Permit 10-04

PART C: PROCESS DESCRIPTION (CONTINUED) 32. List chemicals and metals used in processes (raw materials): 1) 3) 5) 7) 9) 11) 13) 15) 17) 19) 2) 4) 6) 8) 10) 12) 14) 16) 18) 20)

33. If production-based standards apply, list the amount of production (in units expressed by the standards) that passes through (or will pass through) each process that is subject to a standard (attach list if needed):

PART D: INTAKE WATER INFORMATION 34. In the table below, list intake water sources and volumes: SOURCE a. Municipal Water System*
*Specify City:

VOLUME (GPD)

b. c. d.

Private Well Surface water Other**
**Specify:

(Continued on page 5)
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Indiana Department of Environmental Management Office of Water Quality

Application for Industrial Wastewater Pretreatment (IWP) Permit 10-04

PART E: WATER LOSS INFORMATION 35. For the following items, provide the average volume of discharge or water loss (GPD). a. Natural outlet or storm sewer: i) GPD

Do you have an NPDES permit for the discharge to the Natural Outlet or Storm Sewer? Yes* No

ii)

*If yes, provide the permit number: GPD GPD GPD GPD *Specify:

b. Waste hauler: c. Evaporation: d. Contained in product: e. Other*:

PART F: WASTEWATER DISCHARGE(S) TO SANITARY OR COMBINED SEWERS 36. For each line to the municipal sewer, list average wastewater discharge (actual, expected or potential - please specify by checking the appropriate box) from the following sources prior to pretreatment (if any). With a checkmark, indicate the Outfall to which the waste-stream discharges (if there are additional outfalls, please attach additional copies of this page of the form): Source WW Discharge Volume (GPD) Volume Based On (Check One) Actual Volume Expected Volume Actual Volume Expected Volume Actual Volume Expected Volume Actual Volume Expected Volume Actual Volume Expected Volume Actual Volume Expected Volume Actual Volume Expected Volume Actual Volume Expected Volume Outfall Outfall Outfall #1 #2 #3

a. b. c. d. e. f. g. h.

Process Waste-stream #1 Process Waste-stream #2 Process Waste-stream #3 Pretreatment Discharge (if any) Boiler Blowdown Non-contact Cooling Water (once through) Sanitary Water Other Specify:

Include an attachment describing how each flow (36 a.-h. above) is generated (Continued on page 6)

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Indiana Department of Environmental Management Office of Water Quality

Application for Industrial Wastewater Pretreatment (IWP) Permit 10-04

PART G: WASTEWATER DISCHARGE(S) TO SANITARY OR COMBINED SEWERS (DETAILS) 37. Is the discharge to the sewer? a. Continuous b. batch* *If batch discharge, i) Provide the frequency of discharge occurrence: ii) What is the average volume (in gallons) of each batch? 38. Do you have, or plan to have, automatic sampling equipment or continuous wastewater flow metering equipment at this facility? 1 a. Flow metering equipment Yes No N/A b. Sampling equipment Yes
1

No

N/A

39. If "Yes" for item #38a or #38b, describe the type of flow meter(s) and sampling equipment.

40. Are any process changes or expansions planned in the immediate future that could alter wastewater volumes or characteristics? (Consider production processes as well as air or water pollution treatment processes that may affect the discharge). Yes No

41. Are any materials or water reclamation systems in use or planned? 2 Yes** No 42. **If "Yes" for Item #41, describe the recovery process, substances recovered, percent recovered, and the concentrations in the spent solution. Submit a flow diagram for each process. (Attach additional sheets if needed):

PART H: CHARACTERISTICS OF DISCHARGE BUILDING LAYOUT Submit scale drawings (or blueprints) showing the location of each building on the premises. Show map orientation and location of all water meters, storm drains, numbered unit processes (from schematic flow diagram), and public sewers. Show existing and/or proposed sampling locations. SCHEMATIC FLOW DIAGRAM For each major activity in which wastewater is or will be generated, on an attached sheet, draw a diagram of the flow of materials, products, water, and wastewater from start of the activity to its completion, showing all unit processes. Indicate which processes use water and which generate wastestreams. Include the average daily volume and maximum daily volume of each wastestream (new facilities or new dischargers may estimate). If estimates are used for flow data this must be indicated. Number each unit process having wastewater discharges to the community sewer. (Continued on page 7)
If the facility has, or will have, automatic sampling equipment or continuous wastewater flow metering equipment, please indicate the present or future location of this equipment on the sewer schematic (Part H: Schematic Flow Diagram). 2 If Yes, attach a description of these changes and their effects on the wastewater volume and characteristics. Page 6 of 9
1

Indiana Department of Environmental Management Office of Water Quality

Application for Industrial Wastewater Pretreatment (IWP) Permit 10-04

PART I: SEWER INFORMATION Existing Facility 43. If source is not connected to sanitary sewer, has the source applied for sanitary sewer hookup? Yes No NEW FACILITY OR NEW DISCHARGER 44. Will the source be connected to the public sanitary sewer system? Yes No PART J: TREATMENT 45. Is any form of wastewater treatment practiced at this facility? Yes No

46. Do you have a certified operator for your pretreatment facility? Yes No

47. Is any form of wastewater treatment (or changes to an existing wastewater treatment) planned for this facility within the immediate future? Yes* No *If yes, please describe:

48. Description of Pretreatment: Include step-by-step procedure, including any process equipment, design capacity, and operating conditions. Attach a process-flow diagram of the pretreatment.

Attach a process-flow diagram of the pretreatment. PART K: SAMPLING DATA 49. Attach any representative sampling data3 pertaining to the facility discharge to the sewer system. Explain below and/or in the attachment(s) where and when the sampling was accomplished, what type of sample was taken (i.e., grab, composite), and how many samples were analyzed. Be sure the sampling and analytical methods conform to 40 CFR Part 136. If they do not, indicate what method was used.

Attach any sampling data pertaining to the facility discharge to the sewer system. (Continued on page 8)
3

3

If no sampling data is available, testing must be performed on the discharge for any pollutant believed to be present. The sample must be a 24-hour composite taken during normal production activity and/or representing typical wastewater flows. A representative list of pollutants is contained in Table I (on page 10 of this application). Please check the pollutants you know or suspect of being in your discharge. New facilities should use the table to indicate what pollutants will be present or suspected tobe present in proposed wastestreams. Page 7 of 9

Indiana Department of Environmental Management Office of Water Quality

Application for Industrial Wastewater Pretreatment (IWP) Permit 10-04

PART L: SPILL PREVENTION 50. Do you have chemical storage containers, bins, or ponds at your facility? Yes No

51. Do you have floor drains in your manufacturing or chemical storage area(s)? Yes** No **If yes, identify where they discharge to:

Attach a list of the types and quantity of chemicals used or planned for use. Copies of Manufacturer's Safety Data Sheets (MSDS) may be requested for additional information. PART M: NON-DISCHARGED WASTES 52. Are any waste liquids or sludges generated and not disposed of in the sanitary sewer system? Yes* No *If YES, provide the following information (attach additional sheets if necessary): Waste(s) Generated a. b. c. d. e. f. g. h. i. j. Quantity
(per year; specify units)

Disposal Method

PART N: ADMINISTRATIVE OPERATIONS AND PROCEDURES ACT (AOPA) On copies of the form entitled, "Identification Of Potentially Affected Persons" (Form # 49456) (available from the IDEM Office of Water Quality or on the Internet at http://www.IN.gov/icpr/webfile/formsdiv/49456.pdf ), list the names and addresses of all persons who, to your knowledge, may be potentially affected by the discharge from your facility. The AOPA (Administrative Operations And Procedures Act) requires such parties to be individually notified by IDEM when the proposed and final permit is public noticed. Persons not notified may have the final permit rendered null and void if they have been substantially prejudiced by the lack of notice. (Continued on page 9)

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Indiana Department of Environmental Management Office of Water Quality

Application for Industrial Wastewater Pretreatment (IWP) Permit 10-04

PART O: AUTHORIZED REPRESENTATIVE STATEMENT "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/Title

Date (mm/dd/yyyy)

Signature

Phone # ((xxx) xxx-xxxx)

Page 9 of 9

TABLE 1: POLLUTANTS OF CONCERN PRIORITY POLLUTANTS LIST (40 CFR 403, APENDIX B) TOXIC ORGANICS: AROMATICS Benzene Benzene, chloroBenzene, 1,2-dichloroBenzene, 1,3-dichloroBenzene, 1,4-dichloroBenzene, hexachloro-; HCB Benzene, ethylBenzene, nitroToluene Toluene, 2,4-dinitro-; DNT Toluene, 2,6-dinitroBenzene, 1,2,4-trichloroTOXIC ORGANICS: POLYNUCLEAR AROMATIC HYDROCARBONS (PAHs) 2-Chloronaphthalene Benzo (a) anthracene Benzo (b) fluoranthene; B(b)F Benzo (k) fluoranthene; B(k)F Benzo (a) pyrene; B(a)P Ideno (1,2,3-cd) pyrene; IP Dibenzo (a,h) anthracene; DBA Benzo (ghi) perylene Acenaphthene Acenaphthylene Anthracene Chrysene Fluoranthene Fluorene Naphthalene Phenanthrene Pyrene TOXIC ORGANICS: PCB's PCB-1016; Aroclor 1016 PCB-1221; Aroclor 1221 PCB-1232; Aroclor 1232 PCB-1242; Aroclor 1242 PCB-1248; Aroclor 1248 PCB-1254; Aroclor 1254 PCB-1260; Aroclor 1260 TOXIC ORGANICS: HALOGENATED ALIPHATIC HYDROCARBONS Methane, chloro-; methyl chloride Methane, dichloro-; Methylene chloride Methane, trichloro-; chloroform Methane, tetrachloro-; Carbon tetrachloride Methane, bromo-; methyl bromide Methane, dichlorobromoMethane, chlorodibromomMethane, tribromo-; bromoform Ethane, chloro-

HEAVY METALS AND INORGANICS Antimony (Sb)md Arsenic (As) Asbestos Beryllium (Be) Cadmium (Cd) Chromium (Cr) Copper (Cu) Cyanides (CN) Lead (Pb) Mercury (Hg) Nickel (Ni) Selenium (Se) Silver (Ag) Thallium (Tl) Zinc (Zn) TOXIC ORGANICS: ETHERS Ether, bis(2-chloroethyl) Ether, bis(2-chloroisopropyl) Ether, 2-chloroethyl vinyl Ether, 4-chlorophenyl phenyl Ether, 4-bromophenyl phenyl Bis (2-chloroethoxy) methane TOXIC ORGANICS: PHTHALATES Phthalate, dimethyl; DMP Phthalate, diethyl; DEP Phthalate, di-n-butyl; DBP Phthalate, di-n-octyl; DOP Phthalate, bis(2-ethylhexyl); DEHP Phthalate, butyl benzyl; BBP

TOXIC ORGANICS: NITROGEN COMPOUNDS Nitrosamine, dimethylNitrosamine, diphenylNitrosamine, di-n-propylBenzidine Benzidine, 3,3'-dichloroHydrazine, 1,2-diphenylAcrylonitrile TOXIC ORGANICS: PHENOLS Phenol Phenol, 2-chloro Phenol, 2,4-dichloro-; 2,4-DCP Phenol, 2,4,6-trichloroPhenol, pentachloro-; PCP Phenol, 2-nitroPhenol, 4-nitroPhenol, 2,4-dinitro-; 2,4-DNP Phenol, 2,4-dimethylm-Cresol, p-chloroo-Cresol, 4,6-dinitro-; DNOC

TABLE 1: POLLUTANTS OF CONCERN (CONTINUED) TOXIC ORGANICS: HALOGENATED ALIPHATIC HYDROCARBONS Ethane, 1,1-dichloroEthane, 1,2-dichloroEthane, 1,1,1-trichloroEthane, 1,1,2-trichloroEthane, 1,1,2,2-tetrachloroEthane, hexachloroEthylene, chloro-; Vinyl Chloride Ethylene, 1,1-dichloro-; 1,1-DCE Ethylene, 1,2-trans-dichloroEthylene, trichloro-; TCE Ethylene, tetrachloro-; Perchloroethylene Propane, 1,2-dichloroPropylene, 1,3-dichloroButadiene, hexachloro-; HCBD Cyclopentadiene, hexachloro-; HCCPD TOXIC ORGANICS: PESTICIDES alpha-Endosulfan Endosulfan sulfate beta-Endosulfan Hexachlorocyclohexanes: CONVENTIONAL POLLUTANTS: (LISTED IN 40 CFR 401.16) Biochemical Oxygen Demand (BOD) pH (Acid or Base) Total Suspended Solids (TSS) Oil and Grease (O&G) NONCONVENTIONAL POLLUTANTS OF CONCERN: (NOT LISTED AS TOXIC OR CONVENTIONAL) Ammonia (NH3) Chlorides (Cl-1) Sulfides (S-2) Total Dissolved Solids (TDS) Phosphate (PO4) Chemical Oxygen Demand (COD)

alpha-BHC beta-BHC gamma-BHC delta-BHC; Lindane Aldrin; HHDN Dieldrin; HEOD 4,4'-DDE 4,4'-DDT; p,p'-DDT 4,4'-DDD; p,p'-DDD; p,p'-TDE Endrin Endrin aldehyde Heptachlor Heptachlor epoxide Chlordane Toxaphene TOXIC ORGANICS: OXYGENATED COMPOUNDS Acrolein TOXIC ORGANICS: MISCELLANEOUS Isophorone 2,3,7,8-tetrachlorodibenzo-p-dioxin; TCDD; dioxin

APPENDIX: CONTACT PEOPLE AND MAILING ADDRESSES The Office of Water Quality has a contact person for each of the areas that apply to pretreatment. The name and telephone number is listed below for each contact person. Correspondences should be sent to the address below to the attention of the appropriate contact. General Address: Indiana Department of Environmental Management Office of Water Quality 100 North Senate Avenue Indianapolis, Indiana 46204 Contacts : (Direct correspondence to the individuals below by adding "Attention: {Insert Contact Name Listed Below}" to the address) For IWP Permits: Contact: Industrial NPDES Permits Section Telephone: 317/232-8760 For Construction Permits: Contact: Facility Construction Section Telephone: 317/232-8645