Form W (MO780-2112) "Concentrated Animal Feeding Operation (Cafo) Operating Permit Application" - Missouri

What Is Form W (MO780-2112)?

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

Form Details:

  • Released on September 1, 2019;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • 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 Form W (MO780-2112) by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
WATER PROTECTION PROGRAM
JETPAY CONFIRMATION / CHECK NUMBER:
FORM W - CONCENTRATED ANIMAL FEEDING OPERATION
DATE RECEIVED
FEE SUBMITTED
(CAFO) OPERATING PERMIT APPLICATION
Complete all applicable sections. Instructions for completing the form are located at the end of the form. Sign, date and return the form and
all requested documents along with a check for the appropriate permit fee to the Missouri Department of Natural Resources. Make a copy
of this completed form and keep it with your nutrient management plan.
PART 1 – PERMIT OWNERSHIP AND CONTACT INFORMATION
1. 1 OPERATION NAME
CURRENT PERMIT NUMBER
COUNTY
MO-
PHYSICAL ADDRESS
LEGAL DESCRIPTION
TELEPHONE NUMBER WITH AREA CODE
Sec.:
Twn.:
Rng.:
CITY
STATE
ZIP CODE
1.2 OWNER (PROVIDE LEGAL NAME)
EMAIL ADDRESS
MAILING ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
1.3 CONTINUING AUTHORITY (IF DIFFERENT THAN THE OWNER)
MAILING ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
PART 2 – PERMIT TYPE AND PERMIT ACTION
2.1 PERMIT TYPE
2.2 PERMIT ACTION*
NPDES Site Specific Permit
New Permit
Request review of draft permit prior to public notice.
Yes
No
Permit fees may be payed online by credit card or eCheck through a system
called JetPay. Use the URL provided to make an online payment.
NPDES Site Specific Permit -
https://magic.collectorsolutions.com/magic-
ui/payments/mo-natural-resources/591/
NPDES General Permit (MOG01)
NPDES General Permit (MOG01) -
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-
resources/599/
State No-Discharge General Permit (MOGS1)
State No-Discharge General Permit (MOGS1) -
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-
resources/742/
Renewal
Modification
Permit fees may be payed online by credit card or eCheck through a system
called JetPay. Use the URL provided to access JetPay and make an online
payment. Modification fee:
https://magic.collectorsolutions.com/magic-
ui/payments/mo-natural-resources/596/
Ownership Transfer
_______________________________________
PREVIOUS OWNERS NAME
________________________________________
ADRESS
________________________________________
CITY
STATE
ZIP CODE
________________________________________
SIGNATURE
DATE
.
*See instructions for additional requirements and documents for the request permit action
Permit fees may be payed online by credit card or eCheck through a system
called JetPay. Use the URL provided to access JetPay and make an online
payment. Modification fee:
https://magic.collectorsolutions.com/magic-
ui/payments/mo-natural-resources/596/
MO 780-2112 (09-19)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
WATER PROTECTION PROGRAM
JETPAY CONFIRMATION / CHECK NUMBER:
FORM W - CONCENTRATED ANIMAL FEEDING OPERATION
DATE RECEIVED
FEE SUBMITTED
(CAFO) OPERATING PERMIT APPLICATION
Complete all applicable sections. Instructions for completing the form are located at the end of the form. Sign, date and return the form and
all requested documents along with a check for the appropriate permit fee to the Missouri Department of Natural Resources. Make a copy
of this completed form and keep it with your nutrient management plan.
PART 1 – PERMIT OWNERSHIP AND CONTACT INFORMATION
1. 1 OPERATION NAME
CURRENT PERMIT NUMBER
COUNTY
MO-
PHYSICAL ADDRESS
LEGAL DESCRIPTION
TELEPHONE NUMBER WITH AREA CODE
Sec.:
Twn.:
Rng.:
CITY
STATE
ZIP CODE
1.2 OWNER (PROVIDE LEGAL NAME)
EMAIL ADDRESS
MAILING ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
1.3 CONTINUING AUTHORITY (IF DIFFERENT THAN THE OWNER)
MAILING ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
PART 2 – PERMIT TYPE AND PERMIT ACTION
2.1 PERMIT TYPE
2.2 PERMIT ACTION*
NPDES Site Specific Permit
New Permit
Request review of draft permit prior to public notice.
Yes
No
Permit fees may be payed online by credit card or eCheck through a system
called JetPay. Use the URL provided to make an online payment.
NPDES Site Specific Permit -
https://magic.collectorsolutions.com/magic-
ui/payments/mo-natural-resources/591/
NPDES General Permit (MOG01)
NPDES General Permit (MOG01) -
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-
resources/599/
State No-Discharge General Permit (MOGS1)
State No-Discharge General Permit (MOGS1) -
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-
resources/742/
Renewal
Modification
Permit fees may be payed online by credit card or eCheck through a system
called JetPay. Use the URL provided to access JetPay and make an online
payment. Modification fee:
https://magic.collectorsolutions.com/magic-
ui/payments/mo-natural-resources/596/
Ownership Transfer
_______________________________________
PREVIOUS OWNERS NAME
________________________________________
ADRESS
________________________________________
CITY
STATE
ZIP CODE
________________________________________
SIGNATURE
DATE
.
*See instructions for additional requirements and documents for the request permit action
Permit fees may be payed online by credit card or eCheck through a system
called JetPay. Use the URL provided to access JetPay and make an online
payment. Modification fee:
https://magic.collectorsolutions.com/magic-
ui/payments/mo-natural-resources/596/
MO 780-2112 (09-19)
PART 3 – DESIGN CAPACITY FOR MANURE STORAGE AND ANIMALS OF EACH CAFO FEATURE
3.1 STORAGE STRUCTURE TYPES, AMOUNT OF STORAGE, AND AMOUNT OF MANURE GENERATED PER YEAR.
List All Manure Storage Structures at each CAFO Feature
Dry Manure Handling System
Wet Manure Handling System
Permitted
Design Dry Process
Days of
Total Storage
Design Wastewater
Days of
Design
Storage Structure Type(s)
Feature
Waste (tons/yr.)
Storage
Capacity (gal)
per Year (gal./yr.)
Storage
Flow MGD
001
002
003
004
005
3.2 LIST EACH TYPE OF ANIMAL IN CONFINEMENT AND THE NUMBER OF EACH ANIMAL TYPE.
Permitted
Animal
Animal
Animal
Animal Category #1
Animal Category #2
Animal Category #3
Feature
Numbers
Numbers
Numbers
001
002
003
004
005
PART 4 – OPERATIONAL INFORMATION
4.1 OPERATIONAL INFORMATION (SEE INSTRUCTIONS)
SIC Code(s)
CAFO Class Size
4.2 Is this an export-only operation?
Yes
No
Completing PARTS 5 - 11 will meet the requirements of a Nutrient Management Plan (NMP) for an export only operation.
PART 5 – MANURE STORAGE
5.1 Do all manure storage structures have adequate storage, and operated and maintained as no discharge?
Yes
No
PART 6 – ANIMAL MORTALITY
.
6.1 PEMANENT METHOD OF DISPOSING OF ROUTINE ANIMAL MORTALITIES
Composting
Rendering
Send to a Landfill
Incineration
Other (Describe)
6.2 DESCRIBE METHOD OF MORTALITY HANDLING AND STORAGE THROUGH ALL PHASES TO FINAL DISPOSAL. (EXAMPLE: MORTALITIES ARE COMPOSTED WITHIN 24 HOURS OF DEATH AND
FINISHED COMPOST PRODUCT IS STORED UNDER ROOF UNTIL LAND APPLIED). ALSO DESCRIBE THE TYPE OF COMPOST STRUCTURE USED, IF APPLICABLE.
PART 7 – DIVERSION OF CLEAN WATER
7.1 Is clean stormwater diverted from the production area?
Yes
No
7.2 IF YES, DESCRIBE CONTROLS AND MEASURES USED TO DIVERT STORMWATER.
7.3 IF NO, DESCRIBE HOW CONTAMINATED STORMWATER IS CONTAINED AND INCLUDE THE STORAGE CAPACITY OF THE CONTAINMENT IF NOT PREVIOUSLY PROVIDED.
PART 8 – PREVENT DIRECT CONTACT OF ANIMALS WITH SURFACE WATERS
8.1 Do the animals have access to waters of the state within the production area?
Yes
No
8.2 LIST MEASURES USED TO PREVENT CONFINED ANIMAL FORM HAVING DIRECT CONTACT WITH WATERS OF THE STATE.
PART 9 – CHEMICAL HANDLING
Are chemicals and other contaminants handled, managed, stored, and disposed of in accordance with 10 CSR 20-6.300(5)(E)?
9.1
Yes
No
PART 10 – MANURE ANALYSIS TESTING
10.1 LIST EACH TYPE OF MANURE SOURCE.TO BE TESTED ANNUALLY (i.e., MANURE, LITTER, COMPOST, WASTE WATER.)
10.2 DESCRIBE PROCEDURES FOR ENSURING EACH MANURE SOURCE IS TESTED ANNUALLY.
PART 11 – RECORD KEEPING
11.1 Are records of all inspections, manure transfers, discharges and land application maintained?
Yes
No
MO 780-2112 (09-19)
PART 12 – 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 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
SIGNATURE
DATE
PART 13 - ENGINEER CERTIFICATION
As of Aug. 28, 2013, construction permits are only required for the construction of an earthen storage structure to hold, convey, contain,
store, or treat domestic, agricultural, or industrial process wastewater. Construction of all other point source systems designed to hold,
convey, contain, store, or treat domestic, agricultural, or industrial process waste must be designed by a professional engineer registered in
Missouri in accordance with design regulations.
Operation Name
Engineer Firm
Address
Address
City
City State Zip Code
ENGINEER SEAL
I, Project Engineer, certify that above described systems have
been designed in accordance with Missouri CAFO design
regulations in 10 CSR 20-8.300
PROJECT ENGINEER SIGNATURE
MO 780-2112 (09-19)
LAND APPLICATION INFORMATION TABLE (REQUIRED FOR NPDES PERMTS ONLY)
Operation Name:
Class Size:
Permit #:
County:
1
Crop #1
Crop #2
Crop #3
Crop #4
Crop #5
N or P
Legal
Spreadable
P Loss
Based
Yield
Yield
Yield
Yield
Yield
2
3
3
3
3
3
Field Name
Description
Acres
Risk
Application
Crop
Goal
Crop
Goal
Crop
Goal
Crop
Goal
Crop
Goal
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
1
If more than five planned or alternative crops per field continue on next line.
2
Soil Test P Rating or P Index Rating may be used.
3
Express yield in Bu=Bushels or T=Tons per acre.
MO 780-2112 (09-19)
INSTRUCTIONS
FEES
Applicants can pay fees online by credit card or eCheck through a system called JetPay.
Per Section 37.001, RSMo, a transaction fee will be included. The transaction fee is paid to the third party vendor JetPay, not
the Department of Natural Resources.
Be sure to select the correct fee type and corresponding URL to ensure your payment is applied appropriately. If you are
unsure what type of fee to pay, please contact the Water Protection Program’s Budget, Fees, and Grants Management Unit
by phone at 573-522-1485 for assistance.
Upon successful completion of your payment, JetPay provides a payment confirmation. Submit this form with a copy of the
payment confirmation if requesting a new permit or a permit modification. For permit renewals of active permits, the
department will invoice fees annually in a separate request.
If you are unable to make your payment online, but want to pay with credit card, you may email your name, phone number,
and invoice number, if applicable, to WPPFees@dnr.mo.gov. The Budget, Fees, and Grants Management Unit will contact
you to assist with the credit card payment. Please do not include your credit card information in the email.
Applicants can find fee rates in 10 CSR 20-6.011 (https://dnr.mo.gov/pubs/pub2564.htm).
Permit fees may be payed online by credit card or eCheck through a system called JetPay. Use the URL provided below to make the
appropriate online payment.
NEW NPDES Site Specific Permit -
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/591/
NEW NPDES General Permit (MOG01) -
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/599/
NEW State No-Discharge General Permit (MOGS1) -
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-
resources/742/
Modifications or Ownership Transfers-
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/596/
PART 1 - PERMIT OWNERSHIP AND CONTACT INFORMATION
1.1 General location and contact information for the operation. Do not use P.O. Box or RR as physical address of the operation.
1.2 Provide the name of the legal entity that owns or operates the CAFO facility.
1.3 List the Continuing Authority, if it is the same as the Owner enter “Same as above”.
Continuing Authority – A continuing authority is a company, business, entity or person(s) that will be operating the facility and/or
ensuring compliance with the permit requirements. A continuing authority is not, however, an entity or individual that is
contractually hired by the permittee to sample or operate and maintain the system for a defined time period, such as a certified
operator or analytical laboratory. To access the regulatory requirement regarding continuing authority, 10 CSR 20-6.010(2), visit
https://s1.sos.mo.gov/cmsimages/adrules/csr/current/10csr/10c20-6.pdf. A continuing authority’s name must be listed exactly as it
appears on the Missouri Secretary of State’s (SoS’s) webpage:
https://bsd.sos.mo.gov/BusinessEntity/BESearch.aspx?SearchType=0, unless the continuing authority is an individual(s),
government, or otherwise not required to register with the SoS.
PART 2 - PERMIT TYPE
2.1 Check only one box. Indicate which permit you are applying for. EPA regulations require CAFO’s that discharge to obtain a
NPDES (general or site specific) permit. State Regulations require all Class I CAFO’s that do not seek coverage under a NPDES
permit to obtain a State No-Discharge General Permit.
2.2 Indicate which type of permit action is being requested. Application for NPDES permit must also complete Land Application
Information Table.
The following additional documents must be submitted for applications for new permits or permit modifications:
Title page of engineering documents or similar document, or complete Part 13. Required only for construction of new
confinements or manure storage structures. This must include name and address of the operation, date prepared, name and
address of firm preparing the report, seal and signature of the engineer, and a statement indicating the project was designed in
accordance with 10 CSR 20-8.300.
Narrative project summary. This shall include the number of confinement buildings, the design capacity in animal units and
animal numbers for each type of animal, and an explanation of the manure management system and any proposed
modifications.
An aerial and topographic map showing the extent of the production area including all confinement buildings, open lots,
manure storage structures surface water and areas subject to a one hundred year flood event within or adjacent to the
production area, and production area setback distances in accordance with 10 CSR 20-6.300(2)(E)2.D.
Nutrient Management Plan. NPDES permit applications for a new or modified permit shall include the operations nutrient
management plan. For State no-discharge permit applications for a new permit shall include the operations nutrient
management plan. If the operation is export only, completing Parts 5-11 meets this requirement.
Proof of neighbor notice to all parties listed in section 640.715 RSMo, and map(s) that meet the requirement of 10 CSR 20-
6.300(3)(C)2.
Applications for renewal of a NPDES permit shall include the NMP.
Ownership transfers must have previous owner name, address and signature.
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