Free 53895.pdf - Indiana

Reset Form

APPLICATION FOR PERMIT TO DISCHARGE STORM WATER DISCHARGES ASSOCIATED WITH INDUSTRIAL ACTIVITY
State Form 53895 (1-09) / NPDES Application 2F INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT / OFFICE OF WATER QUALITY

EPA Identification Number (copy from Item 1 of Form 1)

I. OUTFALL LOCATION
For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water.
A. OUTFALL NUMBER B. LATITUDE
1. DEG. 2. MIN. 3. SEC.

C. LONGITUDE
1. DEG. 2. MIN. 3. SEC.

D. RECEIVING WATER (name)

II. IMPROVEMENTS
A. Are you now required by any Federal, State, or local authority to meet any implementation schedule for the construction, upgrading, or operation of wastewater treatment equipment or practices or any other environmental programs which may affect the discharges described in this application? This includes, but is not limited to, permit conditions, administrative or enforcement orders, enforcement compliance schedule letters, stipulations, court orders, and grant or loan conditions. 1. Identification of Conditions, 2. Affected Outfalls 3. Brief Description of Project 4. Final Compliance Date (month, day, year) Agreements, Etc. number source of discharge a. req. b. proj.

B. You may attach additional sheets describing any additional water pollution or environmental projects, which may affect your discharges, that you may now have under way or which you plan. Indicate whether each program is now under way or planned, and indicate your actual or planned schedules for construction.

III. SITE DRAINAGE
Attach a site map showing topography (or indicating the outline of drainage areas served by the outfall(s) covered in the application if a topographic map is unavailable) depicting the facility including each of its intake and discharge structures; the drainage area of each storm water outfall; paved areas and buildings within the drainage area of each storm water outfall; each known past or present areas used for outdoor storage or disposal of significant materials; each existing structural control measure to reduce pollutants in storm water runoff, materials loading, and access areas; areas where pesticides, herbicides, soil conditioners, and fertilizers are applied; each of its hazardous waste treatment, storage, or disposal units (including each area not required to have a RCRA permit, which is used for accumulating hazardous waste under 40 CFR 262.34); each well where fluids from the facility are injected underground; springs, and other surface water bodies which receive storm water discharges from the facility.

Page 1 of 3

EPA Identification Number (copy from Item 1 of Form 1)

Outfall Number

IV. NARRATIVE DESCRIPTION OF POLLUTANT SOURCES
A. For each outfall, provide an estimate of the area (include units) of impervious surfaces (including paved areas and building roofs) drained to the outfall, and an estimate of the total surface area drained by the outfall. Outfall Area of Impervious Surface Total Area Drained Outfall Area of Impervious Surface Total Area Drained Number (provide units) (provide units) Number (provide units) (provide units)

B.

Provide a narrative description of significant materials that are currently or in the past three years have been treated, stored or disposed in a manner to allow exposure to storm water; method of treatment, storage, or disposal; past and present materials management practices employed, in the last three years, to minimize contact by these materials with storm water runoff; materials loading and access area; and the location, manner, and frequency in which pesticides, herbicides, soil conditioners, and fertilizers are applied.

C.

For each outfall, provide the location and a description of existing structure and nonstructural control measures to reduce pollutants in storm water runoff; and a description of the treatment the storm water receives, including the schedule and type of maintenance for control and treatment measures and the ultimate disposal of any solid or fluid wastes other than by discharge. Outfall List Codes from Number Treatment Table 2f-1

V. NONSTORMWATER DISCHARGES
A . I certify under penalty of law that the outfall(s) covered by this application have been tested or evaluated for the presence of nonstormwater discharges, and that all nonstormwater discharges from these outfall(s) are identified in either an accompanying Form 2C or Form 2E application for the outfall. Name and Official Title ( type or print) Signature Date Signed (month, day, year)

B. Provide a description of the method used, date of any testing, and the onsite drainage points that were directly observed during a test.

VI. SIGNIFICANT LEAKS OR SPILLS
Provide existing information regarding the history of significant leaks or spills or toxic or hazardous pollutants at the facility in the last three years, including the approximate date and location of the spill or leak, and the type and amount of material released.

Page 2 of 3

EPA Identification Number (copy from Item 1 of Form 1)

Outfall Number

VII. DISCHARGE INFORMATION
A,B,C,&D. See instructions before proceeding. Complete one set of tables for each outfall. Annotate the outfall number in the space provided. Tables VIII-A, VIII-B, and VIII-C are included on separate sheets numbered VII-1 and VII-2. E. Potential discharges not covered by analysis: Is any pollutant listed in Table 2F-2 a substance or a component of a substance which you currently use or manufacture as an intermediate or final product or byproduct? Yes ( list all such pollutants below) No (go to Section IX)

VIII. BIOLOGICAL TOXICITY TESTING DATA
Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on any of your discharges or on a receiving water in relation to your discharge within the last three (3) years? Yes (list all such pollutants below) No (go to Section IX)

IX. CONTRACT ANALYSIS INFORMATION
Were any of the analyses reported in item V performed by a contract laboratory or consulting firm? Yes (list the name, address, and telephone number of, and pollutants analyzed by, each such laboratory or firm below) A. Name B. Address (number and street, city, state, & ZIP code) No (go to Section X) C. Area Code & Telephone number D. Pollutant Analyzed

X. 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 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." A. Name & Official Title (type or print) B. Area Code and Telephone Number C. Signature D. Date signed (month, day, year)

Page 3 of 3

EPA Identification Number (copy from Item 1 of Form 1)

Outfall Number

VII. DISCHARGE INFORMATION (continued from page 3 of Form 2F)
Part A ­ You must provide the results of at least one analysis for every pollutant in this table. Complete one table for each outfall. See instructions for additional details. Maximum Values Average Values Number of Pollutant (include units) (include units) Storm And Events Grab sample Grab sample CAS Number Sampled Taken During Flow-weighted Taken During Flow-weighted Sources of Pollutants First 30 Composite First 30 Composite (if available) Minutes Minutes Oil and Grease Biological Oxygen Demand (BOD5) Chemical Oxygen Demand (COD) Total Suspended Solids (TSS) Total Kjeidahl Nitrogen Nitrate Plus Nitrite Nitrogen Total Phosphorus pH Minimum Maximum Minimum Maximum Part B ­ List each pollutant that is limited in an effluent guideline which the facility is subject to or any pollutant listed in the facility's NPDES permit for its process wastewater (if the facility is operating under an existing NPDES permit). Complete one table for each outfall. See instructions for additional details and requirements. Maximum Values Average Values Number of Pollutant (include units) (include units) Storm And Events Grab sample Grab sample CAS Number Sampled Taken During Flow-weighted Taken During Flow-weighted Sources of Pollutants Composite First 30 Composite First 30 (if available) Minutes Minutes

Page VII-1

Part C ­ List each pollutant shown in Tables 2F-2, 2F-3, and 2F-4 that you know or have reason to believe is present. Complete one table for each outfall. See the instructions for additional details and requirements. Average Values Number Maximum Values of Pollutant (include units) Storm (include units) And Events Grab sample Grab sample CAS Number Sampled Sources of Pollutants Taken During Flow-weighted Taken During Flow-weighted First 30 Composite First 30 Composite (if available) Minutes Minutes

Part D ­ Provide data for the storm event(s) which resulted in the maximum values for the flow weighted composite sample. 1. 2. 3. 4. 5. 6. Date of Duration Total rainfall Number of hours between Maximum flow rate Total flow from of storm Storm Event during storm event beginning of storm measured during rain event rain event (month, day, year) (in minutes) (in inches) and end of previous (gallons/minuteor (gallons or measurable rain event specify units) specify units)

7. Season sample was taken

8. Form of Precipitation (rainfall, snowmelt)

9. Provide a description of the method of flow measurement or estimate.

Page VII-2