ADEM Form 187 "Npdes Individual Permit Application Supplementary Information for Industrial Facilities" - Alabama

What Is ADEM Form 187?

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 187 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 187 "Npdes Individual Permit Application Supplementary Information for Industrial Facilities" - Alabama

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A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
NPDES I
P
A
NDIVIDUAL
ERMIT
PPLICATION
S
I
I
F
UPPLEMENTARY
NFORMATION FOR
NDUSTRIAL
ACILITIES
Instructions: This form should be used to submit the required supplementary information for an application for an NPDES individual permit for industrial facilities.
The completed application should be submitted to ADEM in duplicate. 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 Section
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
1.
Permittee Name:__________________________________________________________________________________________
2.
NPDES Permit Number: AL________________ (not applicable if initial permit application)
3.
SID Permit Number (if applicable): IU________________
4.
NPDES General Permit Number (if applicable): ALG____________
5.
Facility Location (Front Gate): Latitude: _______________________ Longitude: _______________________
6.
Responsible Official (as described on the last page of this application):
Name: ________________________________________
Title: _________________________________________________
Address:
City:
State:
Zip: _____________________
Phone Number:
Email Address:
7.
Designated Discharge Monitoring Report (DMR) Contact:
Name: ________________________________________
Title: _________________________________________________
Phone Number:
Email Address:
8.
Type of Business Entity:
Corporation
General Partnership
Limited Partnership
Limited Liability Company
Sole Proprietorship
Other (Please Specify) __________________________________________________________________________________
8.
Complete this section if the Applicant’s business entity is a Corporation
a)
Location of Incorporation:
Address:
City:
County:
State:
Zip:
b)
Parent Corporation of Applicant:
Name:
Address:
City:
State:
Zip: _____________________
02/2021
ADEM Form 187 m7
Page 1 of 8
A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
NPDES I
P
A
NDIVIDUAL
ERMIT
PPLICATION
S
I
I
F
UPPLEMENTARY
NFORMATION FOR
NDUSTRIAL
ACILITIES
Instructions: This form should be used to submit the required supplementary information for an application for an NPDES individual permit for industrial facilities.
The completed application should be submitted to ADEM in duplicate. 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 Section
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
1.
Permittee Name:__________________________________________________________________________________________
2.
NPDES Permit Number: AL________________ (not applicable if initial permit application)
3.
SID Permit Number (if applicable): IU________________
4.
NPDES General Permit Number (if applicable): ALG____________
5.
Facility Location (Front Gate): Latitude: _______________________ Longitude: _______________________
6.
Responsible Official (as described on the last page of this application):
Name: ________________________________________
Title: _________________________________________________
Address:
City:
State:
Zip: _____________________
Phone Number:
Email Address:
7.
Designated Discharge Monitoring Report (DMR) Contact:
Name: ________________________________________
Title: _________________________________________________
Phone Number:
Email Address:
8.
Type of Business Entity:
Corporation
General Partnership
Limited Partnership
Limited Liability Company
Sole Proprietorship
Other (Please Specify) __________________________________________________________________________________
8.
Complete this section if the Applicant’s business entity is a Corporation
a)
Location of Incorporation:
Address:
City:
County:
State:
Zip:
b)
Parent Corporation of Applicant:
Name:
Address:
City:
State:
Zip: _____________________
02/2021
ADEM Form 187 m7
Page 1 of 8
c)
Subsidiary Corporation(s) of Applicant:
Name:
Address:
City:
State:
Zip: _____________________
d)
Corporate Officers:
Name:
Address:
City:
State:
Zip: _____________________
Name:
Address:
City:
State:
Zip: _____________________
e)
Agent designated by the corporation for purposes of service:
Name:
Address:
City:
State:
Zip: _____________________
9.
If the Applicant’s business entity is a Partnership, please list the general partners.
Name:
Name:
Address:
Address:
City:
State:
Zip: ___________
City:
State:
Zip: ___________
10. If the Applicant’s business entity is a Proprietorship, please enter the proprietor’s information.
Name:
Address:
City:
State:
Zip: _____________________
11. Identify all Administrative Complaints, Notices of Violation, Directives, Administrative Orders, or Litigation concerning water
if any, against the Applicant, its parent corporation or subsidiary corporations within the State of Alabama within the past five years
(attach additional sheets if necessary):
Facility Name
Permit Number
Type of Action
Date of Action
ADEM Form 187 m7 02/2021
Page 2 of 8
SECTION B – BUSINESS ACTIVITY
If your facility conducts or will be conducting any of the processes listed below (regardless of whether they generate wastewater, waste
sludge, or hazardous waste), 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 (EPA) categorical standards.
These facilities are termed “categorical users”.
SECTION C – WASTEWATER DISCHARGE INFORMATION
1.
Do you share an outfall with another facility?
Yes
No (If no, continue to C.2)
For each shared outfall, provide the following:
Applicant’s
NPDES
Where is sample collected
Name of Other Permittee/Facility
Outfall No.
Permit No.
by Applicant?
ADEM Form 187 m7 02/2021
Page 3 of 8
2.
Do you have, or plan to have, automatic sampling equipment or continuous wastewater flow metering equipment at this facility?
Current:
Flow Metering
Yes
No
N/A
Sampling Equipment
Yes
No
N/A
Planned:
Flow Metering
Yes
No
N/A
Sampling Equipment
Yes
No
N/A
If so, please attach a schematic diagram of the sewer system indicating the present or future location of this equipment and describe
the equipment below:
3.
Are any process changes or expansions planned during the next three years that could alter wastewater volumes or characteristics?
Yes
No (If no, continue to C.4)
Briefly describe these changes and their anticipated effects on the wastewater volume and characteristics:
4.
List the trade name and chemical composition of all biocides and corrosion inhibitors used:
Trade Name
Chemical Composition
For each biocide and/or corrosion inhibitor used, please include the following information:
(1) 96-hour median tolerance limit data for organisms representative of the biota of the waterway into which the discharge will
ultimately reach,
(2) quantities to be used,
(3) frequencies of use,
(4) proposed discharge concentrations, and
(5) EPA registration number, if applicable
SECTION D – 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*
Well Depth:
Ft.
Latitude:
Longitude:
Surface Intake Volume:
MGD*
Intake Elevation in Relation to Bottom:
Ft.
Intake Elevation:
Ft.
Latitude:
Longitude:
Name of Surface Water Source:
* MGD – Million Gallons per Day
ADEM Form 187 m7 02/2021
Page 4 of 8
Cooling Water Intake Structure Information
Complete D.1 and D.2 if your water supply is provided by an outside source and not by an onsite water intake structure? (e.g.,
another industry, municipality, etc…)
1.
Does the provider of your source water operate a surface water intake?
Yes
No
(If yes, continue, if no, go to Section E.)
a) Name of Provider:
b) Location of Provider:
c) Latitude:
Longitude:
2.
Is the provider a public water system (defined as a system which provides water to the public for human consumption or which
provides only treated water, not raw water)?
Yes
No (If yes, go to Section E, if no, continue.)
Only to be completed if you have a cooling water intake structure or the provider of your water supply uses an intake structure
and does not treat the raw water.
3. Is any water withdrawn from the source water used for cooling?
Yes
No
4. Using the average monthly measurements over any 12-month period, approximately what percentage of water withdrawn is
used exclusively for cooling purposes? ___________%
5. Does the cooling water consist of treated effluent that would otherwise be discharged?
Yes
No
(If yes, go to Section E, if no, complete D.6 – D.17)
6. a. Is the cooling water used in a once-through cooling system?
Yes
No
b. Is the cooling water used in a closed cycle cooling system?
Yes
No
7. When was the intake installed? ____________________________________________________________________________
(Please provide dates for all major construction/installation of intake components including screens)
8. What is the maximum intake volume? _________________
(maximum pumping capacity in gallons per day)
9. What is the average intake volume? ___________________
(average intake pump rate in gallons per day average in any 30-day period)
10. What is the actual intake flow (AIF) as defined in 40 CFR §125.92(a)? _________MGD
11. How is the intake operated? (e.g., continuously, intermittently, batch) ______________________________________________
12. What is the mesh size of the screen on your intake?____________________________________________________________
13. What is the intake screen flow-through area?_________________________________________________________________
14. What is the through-screen design intake flow velocity? ___________ft/sec
15. What is the through-screen actual velocity (in ft/sec)? ___________ft/sec
16. What is the mechanism for cleaning the screen? (e.g., does it rotate for cleaning) ____________________________________
17. Do you have any additional fish detraction technology on your intake?
Yes
No
18. Have there been any studies to determine the impact of the intake on aquatic organisms?
Yes
No (If yes, please
provide.)
19. Attach a site map showing the location of the water intake in relation to the facility, shoreline, water depth, etc.
ADEM Form 187 m7 02/2021
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