ADEM Form 391 "Notice of Intent - Npdes General Permit Number Alg250000" - Alabama

What Is ADEM Form 391?

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 October 1, 2017;
  • 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 printable version of ADEM Form 391 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 391 "Notice of Intent - Npdes General Permit Number Alg250000" - Alabama

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A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
N
I
– NPDES G
P
N
ALG250000
OTICE OF
NTENT
ENERAL
ERMIT
UMBER
Instructions: This form should be used to submit a Notice of Intent for coverage under NPDES General Permit Number ALG250000,
which is the general permit authorizing discharges of
non-contact cooling water; uncontaminated condensate; cooling tower
blowdown; boiler blowdown; demineralizer wastewater
. Please mark the “Not Applicable” box if a section is not applicable.
Incomplete or wrong answers could result in more stringent permit requirements. If space is insufficient to address any item below
please continue answer on an attached sheet of paper. Mail completed form to:
ADEM-Water Division
FOR ADEM USE ONLY
Industrial General Permit Section
NPDES PERMIT NUMBER
PO Box 301463
Montgomery, Alabama 36130-1463
FACILITY NUMBER
P
N
I
URPOSE OF THIS
OTICE OF
NTENT
[ ] Initial request for coverage under NPDES General Permit Number ALG250000
[ ] Reissuance of coverage under NPDES General Permit Number ALG250000 (Current Permit No. ALG25________)
[ ] Modification of coverage under NPDES General Permit Number ALG250000 (Current Permit No. ALG25________)
F
I
I
ACILITY
DENTIFICATION
NFORMATION
A. Name of Permittee:
Name of Facility:
B. Mailing Address of Facility: – PO Box or Street Route
City, State and Zip Code
C. Location (STREET ADDRESS) of Facility:
City, County:
D. Provide the latitudinal and longitudinal coordinates of the facility location. (Front Gate):
Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
E. Facility Contact Person:
Name: ____________________________________
Title: ____________________________________________
Phone Number: _____________________________
Email Address: ___________________________________
F. Standard Industrial Code (SIC)
:
[The primary SIC Code should reflect the primary activity of business (i.e. generates the highest revenue)]
SIC Code
SIC Description
1.
(Primary)
2.
(Secondary)
3.
(Tertiary)
G. Description of industrial activity and land use at the facility:
ADEM Form 391 10/17 m5
Page 1 of 7
A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
N
I
– NPDES G
P
N
ALG250000
OTICE OF
NTENT
ENERAL
ERMIT
UMBER
Instructions: This form should be used to submit a Notice of Intent for coverage under NPDES General Permit Number ALG250000,
which is the general permit authorizing discharges of
non-contact cooling water; uncontaminated condensate; cooling tower
blowdown; boiler blowdown; demineralizer wastewater
. Please mark the “Not Applicable” box if a section is not applicable.
Incomplete or wrong answers could result in more stringent permit requirements. If space is insufficient to address any item below
please continue answer on an attached sheet of paper. Mail completed form to:
ADEM-Water Division
FOR ADEM USE ONLY
Industrial General Permit Section
NPDES PERMIT NUMBER
PO Box 301463
Montgomery, Alabama 36130-1463
FACILITY NUMBER
P
N
I
URPOSE OF THIS
OTICE OF
NTENT
[ ] Initial request for coverage under NPDES General Permit Number ALG250000
[ ] Reissuance of coverage under NPDES General Permit Number ALG250000 (Current Permit No. ALG25________)
[ ] Modification of coverage under NPDES General Permit Number ALG250000 (Current Permit No. ALG25________)
F
I
I
ACILITY
DENTIFICATION
NFORMATION
A. Name of Permittee:
Name of Facility:
B. Mailing Address of Facility: – PO Box or Street Route
City, State and Zip Code
C. Location (STREET ADDRESS) of Facility:
City, County:
D. Provide the latitudinal and longitudinal coordinates of the facility location. (Front Gate):
Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
E. Facility Contact Person:
Name: ____________________________________
Title: ____________________________________________
Phone Number: _____________________________
Email Address: ___________________________________
F. Standard Industrial Code (SIC)
:
[The primary SIC Code should reflect the primary activity of business (i.e. generates the highest revenue)]
SIC Code
SIC Description
1.
(Primary)
2.
(Secondary)
3.
(Tertiary)
G. Description of industrial activity and land use at the facility:
ADEM Form 391 10/17 m5
Page 1 of 7
H. Has the facility been issued an NPDES INDIVIDUAL permit?
[ ] Yes
[ ] No If YES, NPDES Permit No. AL00
Do you intend to replace your individual permit with this General Permit? [ ] Yes
[ ] No
I.
Has the facility been issued a State Indirect Discharge (SID) Permit?
[ ] Yes
[ ] No If YES, SID Permit No. IU
J. Has the facility ever been issued coverage under an NPDES GENERAL Permit other than a permit listed in the
“Purpose of this Notice of Intent” section? [ ] Yes
[ ] No
If YES, please provide the following:
Permit Number: AL
Facility Name on Permit:
K. Are any discharges that you intend to be covered by this general permit going to municipal storm sewer or
municipal/private sanitary sewer?
[ ] Yes
[ ] No
L. Name of surface water to which the municipal storm sewer discharges:
M. Have you notified the municipality by letter as required by 40 CFR §122.26(a)(4)? [ ] Yes
[ ] No
N. Date facility started or will start operations:
O. Do you discharge to any waters of the State that are impaired (303(d) or TMDL)? [ ] Yes
[ ] No
(A list of the impaired waters can be found at
http://www.adem.state.al.us/programs/water/303d.cnt
for 303(d) listed
waters and
http://www.adem.state.al.us/programs/water/approvedTMDLs.htm
for waters subject to a TMDL.)
If YES, do your discharges contain pollutants of concern listed for the impaired water(s)? [ ] Yes
[ ] No
If YES, then enhanced BMPs are required. Also, an Individual NPDES Permit may be required, so please contact the
Industrial Section of ADEM’s Water Division before proceeding.
P. Is your facility located in a coastal zone (i.e. within 10-foot contour of sea-level)? [ ] Yes
[ ] No
Q. Does any discharge or runoff from the facility reach a public water supply stream segment as defined by ADEM
Administrative Code r. 335-6-11-.02? [ ] Yes
[ ] No
R. Does any discharge or runoff from the facility reach an Outstanding Alabama Water or Outstanding Natural Resource
Water stream segment as defined by ADEM Administrative Code r. 335-6-11-.02? [ ] Yes
[ ] No
If YES, the facility cannot be covered under this general permit. Please contact the Industrial Section of ADEM’s
Water Division before proceeding.
ADEM Form 391 10/17 m5
Page 2 of 7
DSN001: DISCHARGES ASSOCIATED WITH NON-CONTACT COOLING WATER, COOLING TOWER BLOWDOWN,
UNCONTAMINATED CONDENSATE, BOILER BLOWDOWN, AND DEMINERALIZER WASTEWATER
NOT APPLICABLE [ ]
A. List latitude and longitude (to seconds) of the point where each discharge exits your property (i.e. outfall), name of
receiving stream, and type of discharge (non-contact cooling water, cooling tower blowdown, uncontaminated
condensate, boiler blowdown, or demineralizer wastewater):
1. Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
Receiving Stream
Type of Discharge
2. Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
Receiving Stream
Type of Discharge
3. Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
Receiving Stream
Type of Discharge
4. Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
Receiving Stream
Type of Discharge
5. Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
Receiving Stream
Type of Discharge
B. If more than one discharge is listed for DSN001, can they be sampled separately? [ ] Yes
[ ] No
C. Is there any process water commingled with the cooling and/or blowdown water prior to discharge? [ ] Yes
[ ] No
If YES, can they all be sampled separately prior to commingling? [ ] Yes
[ ] No
D. Does surface water intake total 2 million gallons per day or more? [ ] Yes
[ ] No
If YES, is 25% or more of the surface water intake used for cooling purposes? [ ] Yes
[ ] No
E. Is the non-contact cooling water and the cooling tower blowdown discharge less than 100,000 gallons per day (GPD)?
[ ] Yes
[ ] No
If NO, provide the estimated gallons per day of discharge:
GPD
F. Do you use biocides, corrosion inhibitors, or chemical additives in your cooling or blowdown water? [ ] Yes
[ ] No
If YES, please submit a list of the biocides, corrosion inhibitors, or chemical additives used with this NOI and submit
an MSDS sheet for each biocide or chemical. The applicant must also provide the following information for each
biocide or chemical:
(1) Name and general composition of biocide or chemical (if composition is not provided on MSDS sheet),
ADEM Form 391 10/17 m5
Page 3 of 7
(2) 48-hour or 96-hour LC50 data for organisms representative of the biota of the waterway into which the discharge will ultimately
reach. For freshwater, the fathead minnow (Pimephales promelas) and cladoceran (Ceriodaphnia dubia) are the test organisms.
For salt water, the mysid shrimp and the sheepshead minnow or inland silverside are the test organisms. Other acceptable
aquatic organisms may be allowed by the Department if sufficient information is provided. If the MSDS sheet does not provide
data for the organisms specified above, the facility must provide the data unless the Department grants approval for an alternate
organism.
(3) Quantities to be used,
(4) Frequencies of use,
(5) Maximum proposed discharge concentrations, and
(6) EPA registration of number, if applicable and is not provided on the MSDS sheet.
*BIOCIDES THAT CONTAIN TRIBUTYL TIN, TRIBUTYL TIN OXIDE, ZINC AND/OR CHROMIUM ARE PROHIBITED BY THIS GENERAL PERMIT
G. Is any discharge located in the Tennessee or Cahaba River Basin or on the Tallapoosa River between Thurlow Dam
at Tallassee and the junction of the Coosa River and Tallapoosa River? [ ] Yes
[ ] No
H. Is the boiler blowdown discharge less than 5,000 gallons per day (GPD)? [ ] Yes
[ ] No
If NO, provide the estimated gallons per day of discharge
GPD
I.
Is shock chlorination used at the facility? [ ] Yes
[ ] No
J. Is any source water chlorinated? [ ] Yes
[ ] No If YES, please list the applicable outfall number(s) from DSN001.
K. Is demineralizer wastewater discharged? [ ] Yes
[ ] No
L. Are there any known impacts on the receiving water as a result of any discharges under DSN001? [ ] Yes
[ ] No
If YES, to what extent?
M. Is there a cooling water intake structure (CWIS) associated with this facility? [ ] Yes
[ ] No
N. Does the provider of your source water operate a CWIS? [ ] Yes
[ ] No (Note: If your source water is from a
WTP that also supplies drinking water, then the answer is “No”).
If the answer to either M. or N. above (or both) is YES, then a Cooling Water Intake Structure Form (ADEM Form 510) must
be completed and attached to this NOI.
O. Is cooling/blowdown water chlorine free from the time it enters your facility until it is discharged (Note: city water
usually contains chlorine)? [ ] Yes
[ ] No If YES, skip P. and Q. below.
P. If you answered NO to O. above, is the distance from the point of the facility’s discharge to the point of entry into the
receiving stream greater than 2,500 feet for any of the chlorinated outfalls listed for DSN001?
[ ] Yes
[ ] No If YES, list which outfalls meet this criteria:
For outfalls listed in P. above, you are not required to monitor for chlorine at that outfall if you meet the following
criteria:
1. Submit lab data with the Notice of Intent (NOI) that demonstrates that the chlorine concentration at the point the discharge
enters the impacted stream is 0.011 mg/l or less, AND
2. Submit a site drawing showing that the distance from the discharge point to the point the effluent enters the impacted
stream is greater than 2,500 feet.
ADEM Form 391 10/17 m5
Page 4 of 7
Q. For outfalls listed in P. above, do you intend to exercise the no chlorine monitoring option? [ ] Yes
[ ] No
For which outfall(s)?
If you answered Yes to Q. above, you are certifying by signing this form that the criteria for not being required to
monitor for chlorine have been met and you are certifying that you understand that you are required to notify ADEM if
these conditions change during the term of the permit.
ADEM Form 391 10/17 m5
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