ADEM Form 186 "State Indirect Discharge (Sid) Permit Application" - Alabama

What Is ADEM Form 186?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of ADEM Form 186 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 186 "State Indirect Discharge (Sid) Permit Application" - Alabama

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A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
S
I
D
(SID) P
A
TATE
NDIRECT
ISCHARGE
ERMIT
PPLICATION
Instructions: This form should be used to submit an application for a State Indirect Discharge (SID) permit. The completed application should be submitted to ADEM
in duplicate. A copy of the application should also be submitted to the receiving POTW. If insufficient space is available to address any item, please continue on an
attached sheet of paper. Please mark “N/A” in the appropriate box when an item is not applicable to the applicant. Please type or print legibly in blue or black ink.
Mail the completed application to:
ADEM-Water Division
Industrial/Municipal Branch
P O Box 301463
Montgomery, AL 36130-1463
PURPOSE OF THIS APPLICATION
Initial Permit Application for New Facility*
Initial Permit Application for Existing Facility*
Modification of Existing Permit
Reissuance of Existing Permit
Revocation & Reissuance of Existing Permit
* An application for participation in the ADEM’s Electronic Environmental (E2) Reporting must be
submitted to allow permittee to electronically submit reports as required.
SECTION A – GENERAL INFORMATION
Permittee Name:
1.
2.
SID Permit Number: IU ___ ___ - ___ ___ - ___ ___ ___ ___ ___
3.
NPDES or General NPDES Permit Numbers (if applicable)
4.
Facility Physical Location: (Attach a map with location marked; street, route no. or other specific identifier)
Street:
City:
County:
State:
Zip: _____________________
Latitude:
Longitude:
5.
Facility Mailing Address (Street or Post Office Box):
City:
State:
Zip:
6.
Responsible Official (as described on the last page of this application):
Name and Title:
Address:
City:
State:
Zip:
Phone Number:
Email Address: ___________________________________
7.
Designated Facility Contact:
Name and Title:
Phone Number:
Email Address:________________________________________________________________________________
8. Designated Discharge Monitoring Report Contact:
Name and Title:
Phone Number:
Email Address:________________________________________________________________________________
ADEM Form 186 m6 02/2021
Page 1 of 15
A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
S
I
D
(SID) P
A
TATE
NDIRECT
ISCHARGE
ERMIT
PPLICATION
Instructions: This form should be used to submit an application for a State Indirect Discharge (SID) permit. The completed application should be submitted to ADEM
in duplicate. A copy of the application should also be submitted to the receiving POTW. If insufficient space is available to address any item, please continue on an
attached sheet of paper. Please mark “N/A” in the appropriate box when an item is not applicable to the applicant. Please type or print legibly in blue or black ink.
Mail the completed application to:
ADEM-Water Division
Industrial/Municipal Branch
P O Box 301463
Montgomery, AL 36130-1463
PURPOSE OF THIS APPLICATION
Initial Permit Application for New Facility*
Initial Permit Application for Existing Facility*
Modification of Existing Permit
Reissuance of Existing Permit
Revocation & Reissuance of Existing Permit
* An application for participation in the ADEM’s Electronic Environmental (E2) Reporting must be
submitted to allow permittee to electronically submit reports as required.
SECTION A – GENERAL INFORMATION
Permittee Name:
1.
2.
SID Permit Number: IU ___ ___ - ___ ___ - ___ ___ ___ ___ ___
3.
NPDES or General NPDES Permit Numbers (if applicable)
4.
Facility Physical Location: (Attach a map with location marked; street, route no. or other specific identifier)
Street:
City:
County:
State:
Zip: _____________________
Latitude:
Longitude:
5.
Facility Mailing Address (Street or Post Office Box):
City:
State:
Zip:
6.
Responsible Official (as described on the last page of this application):
Name and Title:
Address:
City:
State:
Zip:
Phone Number:
Email Address: ___________________________________
7.
Designated Facility Contact:
Name and Title:
Phone Number:
Email Address:________________________________________________________________________________
8. Designated Discharge Monitoring Report Contact:
Name and Title:
Phone Number:
Email Address:________________________________________________________________________________
ADEM Form 186 m6 02/2021
Page 1 of 15
9.
Type of Business Entity:
Corporation
General Partnership
Limited Partnership
Sole Proprietorship
Other (Please Specify)
10. Complete this section if the Applicant’s business entity is a corporation:
Location of Incorporation:
Address:
City:
County:
State:
Zip:
Parent Corporation of Applicant:
Name:
Address:
City:
State:
Zip:
Subsidiary Corporation(s) of Applicant:
Name:
Address:
City:
State:
Zip:
Corporate Officers:
Name:
Address:
City:
State:
Zip:
Agent designated by the corporation for purposes of service:
Name:
Address:
City:
State:
Zip:
11. If the Applicant’s business entity is a Partnership, please list the general partners.
Name:
Address:
City:
State:
Zip:
Name:
Address:
City:
State:
Zip:
12. Please complete this section if the Applicant’s business entity is a Proprietorship.
Name:
Address:
City:
State:
Zip:
ADEM Form 186 m6 02/2021
Page 2 of 15
13.
Permit numbers for Applicant’s previously issued NPDES and SID permits; and identification of any other State of Alabama
environmental permits presently held by the Applicant, its parent corporation, or subsidiary corporations within the State of
Alabama:
Permit Name
Permit Number
Held By
14. Identify all Administrative Complaints, Notices of Violation, Directives, Administrative Orders, or Litigation concerning water
pollution, if any, against the Applicant, its parent corporation, or subsidiary corporations within the State of Alabama within the past
five years:
Facility Name
Permit Number
Type of Action
Date of Action
15. Name of Publicly or Privately Owned Treatment Works (POTW) receiving the Applicant’s wastewater
:
(attach letter of acceptance)
_____________________________________________________________________________________________________
POTW NPDES Permit Number: ___________________________________________________________________________
Location: _____________________________________________________________________________________________
Mailing Address: _______________________________________________________________________________________
City:
________________________________ State: ________________________ Zip: ____________________________
POTW Contact: __________________________________________ Phone Number:
______________________________
ADEM Form 186 m6 02/2021
Page 3 of 15
SECTION B – BUSINESS ACTIVITY
1.
If your facility conducts or will be conducting any of the processes listed below (regardless of whether they generate wastewater,
waste sludge, or hazardous wastes), place a check beside the category of business activity (check all that apply):
Industrial Categories
[
]
Aluminum Forming
[
]
Metal Molding and Casting
[
]
Asbestos Manufacturing
[
]
Metal Products
[
]
Battery Manufacturing
[
]
Nonferrous Metals Forming
[
]
Can Making
[
]
Nonferrous Metals Manufacturing
[
]
Canned and Preserved Fruit and Vegetables
[
]
Oil and Gas Extraction
[
]
Canned and Preserved Seafood
[
]
Organic Chemicals Manufacturing
[
]
Cement Manufacturing
[
]
Paint and Ink Formulating
[
]
Centralized Waste Treatment
[
]
Paving and Roofing Manufacturing
[
]
Carbon Black
[
]
Pesticides Manufacturing
[
]
Coal Mining
[
]
Petroleum Refining
[
]
Coil Coating
[
]
Phosphate Manufacturing
[
]
Copper Forming
[
]
Photographic
[
]
Electric and Electronic Components Manufacturing
[
]
Pharmaceutical
[
]
Electroplating
[
]
Plastic & Synthetic Materials
[
]
Explosives Manufacturing
[
]
Plastics Processing Manufacturing
[
]
Feedlots
[
]
Porcelain Enamel
[
]
Ferroalloy Manufacturing
[
]
Pulp, Paper, and Fiberboard Manufacturing
[
]
Fertilizer Manufacturing
[
]
Rubber
[
]
Foundries (Metal Molding and Casting)
[
]
Soap and Detergent Manufacturing
[
]
Glass Manufacturing
[
]
Steam and Electric
[
]
Grain Mills
[
]
Sugar Processing
[
]
Gum and Wood Chemicals Manufacturing
[
]
Textile Mills
[
]
Inorganic Chemicals
[
]
Timber Products
[
]
Iron and Steel
[
]
Transportation Equipment Cleaning
[
]
Leather Tanning and Finishing
[
]
Waste Combustion
[
]
Metal Finishing
[
]
Other (specify)______________
[
]
Meat Products
A facility with processes inclusive in these business areas may be covered by Environmental Protection Agency’s (EPA)
categorical pretreatment standards. These facilities are termed “categorical users”.
2.
Give a brief description of all operations at this facility including primary products or services (attach additional sheets if necessary):
3.
Indicate applicable Standard Industrial Classification (SIC) Codes for all processes (If more than one applies, list in order of
importance.):
a.
b.
c.
d.
e.
ADEM Form 186 m6 02/2021
Page 4 of 15
SECTION C – WATER SUPPLY
Water Sources (check as many as are applicable):
[
]
Private Well
[
]
Surface Water
[
]
Municipal Water Utility (Specify City):
[
]
Other (Specify):
If more than one well or surface intake, provide data for each on an attachment
City:
*MGD
Well:
*MGD
Surface Intake Volume**:
*MGD
Name of Surface Water Source:
Intake Elevation:
Ft.
Latitude:
Longitude:
* - MGD = Million Gallons Per Day
** - If the surface water intake amount is greater than 2.0 MGD, is 25% or more used for cooling purposes?
[
] Yes
[
] No
SECTION D – SEWER INFORMATION
Briefly describe the location of monitoring/sampling points and discharge points to the POTW (the point at which wastewater enters
a sewer not owned by the applicant) for each outfall included in the SID permit application [Narrative description is required]
Outfall Number:
Monitoring/Sampling point:
Discharge point:
Outfall Number:
Monitoring/Sampling point:
Discharge point:
SECTION E – WASTEWATER DISCHARGE INFORMATION
Facilities that checked activities in question 1 of Section B and are considered Categorical Industrial Users should skip to question 2 of
this section.
1.
For Non-Categorical Users Only:
List average wastewater discharge, maximum discharge, and type of discharge (batch,
continuous, or both), for each plant process. Using the process flow schematic (Figure 1, pg 16), enter the description that
corresponds to each process. (The flow schematic should include all treatment units as well as monitoring and discharge
points)[New facilities should provide estimates for each discharge.]
Last 12 Months
Highest Flow Year of Last 5
Discharge Type
(gals/day)
(gals/day)
(batch, continuous,
Process Description
Highest Month Avg. Flow
Monthly Avg. Flow
intermittent)
ADEM Form 186 m6 02/2021
Page 5 of 15
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