ADEM Form 383 "Notice of Intent - Npdes General Permit Number Alg150000" - Alabama

What Is ADEM Form 383?

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 383 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 383 "Notice of Intent - Npdes General Permit Number Alg150000" - Alabama

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A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
N
I
– NPDES G
P
N
ALG150000
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 ALG150000,
which is the general permit authorizing discharges associated with food and kindred product industries consisting of storm water, non-
contact cooling water, cooling tower and boiler blowdown, demineralizer wastewater, vehicle and equipment wash water, and storm
water from petroleum bulk storage and fueling areas, and equipment maintenance areas. Please answer all questions in applicable
sections. 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
FOR ADEM USE ONLY
address any item below please continue answer on an attached sheet of paper.
Mail
completed form to:
NPDES PERMIT NUMBER
ADEM-Water Division
FACILITY NUMBER
Industrial General Permit Section
PO Box 301463
Montgomery, Alabama 36130-1463
P
N
I
URPOSE OF THIS
OTICE OF
NTENT
[ ] Initial request for coverage under NPDES General Permit Number ALG150000
[ ] Reissuance of coverage under NPDES General Permit Number ALG150000 (Current Permit No. ALG15________)
[ ] Modification of coverage under NPDES General Permit Number ALG150000 (Current Permit No. ALG15________)
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 383 10/17 m4
Page 1 of 13
A
D
E
M
(ADEM)
LABAMA
EPARTMENT OF
NVIRONMENTAL
ANAGEMENT
N
I
– NPDES G
P
N
ALG150000
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 ALG150000,
which is the general permit authorizing discharges associated with food and kindred product industries consisting of storm water, non-
contact cooling water, cooling tower and boiler blowdown, demineralizer wastewater, vehicle and equipment wash water, and storm
water from petroleum bulk storage and fueling areas, and equipment maintenance areas. Please answer all questions in applicable
sections. 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
FOR ADEM USE ONLY
address any item below please continue answer on an attached sheet of paper.
Mail
completed form to:
NPDES PERMIT NUMBER
ADEM-Water Division
FACILITY NUMBER
Industrial General Permit Section
PO Box 301463
Montgomery, Alabama 36130-1463
P
N
I
URPOSE OF THIS
OTICE OF
NTENT
[ ] Initial request for coverage under NPDES General Permit Number ALG150000
[ ] Reissuance of coverage under NPDES General Permit Number ALG150000 (Current Permit No. ALG15________)
[ ] Modification of coverage under NPDES General Permit Number ALG150000 (Current Permit No. ALG15________)
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 383 10/17 m4
Page 1 of 13
H. Check the type of discharge at your facility and complete the applicable sections associated with the type checked:
[ ] Storm water discharges associated with food production (DSN001)
[ ] Discharges associated with non-contact cooling water, cooling tower blowdown, uncontaminated condensate,
boiler blowdown, and demineralizer wastewater (DSN003)
[ ] Storm water discharges associated with fueling, petroleum storage and handling, equipment storage, and
maintenance areas (DSN005 and DSN007)
[ ] Discharges associated with vehicle and equipment exterior washing operations (DSN008)
I.
Are any discharges in H. above combined? [ ] Yes
[ ] No If YES, indicate which discharges are combined:
J. 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
K. Has the facility been issued a State Indirect Discharge (SID) Permit?
[ ] Yes
[ ] No If YES, SID Permit No. IU
L. 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:
M. Are any discharges that you intend to be covered by this general permit going to municipal storm sewer?
[ ] Yes
[ ] No
N. Name of surface water to which the municipal storm sewer discharges:
O. Have you notified the municipality by letter as required by 40 CFR §122.26(a)(4)? [ ] Yes
[ ] No
P. Date facility started or will start operations:
Q. What is the size of the site in acres?
R. 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.
S. Is your facility located in a coastal zone (i.e. within 10-foot contour of sea-level)? [ ] Yes
[ ] No
T. 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
U. 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 383 10/17 m4
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DSN001: STORM WATER DISCHARGES ASSOCIATED WITH FOOD PRODUCTION
NOT APPLICABLE [ ]
A. List latitude and longitude (to seconds) of the point where each discharge exits your property (i.e. outfall) and name of
receiving stream:
1. Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
Receiving Stream
2. Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
Receiving Stream
3. Latitude (
) ° (
) ‘ (
) “ N
Longitude (
) ° (
) ‘ (
) “ W
Receiving Stream
B. Has storm water runoff from the facility been analyzed for presence of any known pollutants? [ ] Yes
[ ] No
If YES, attach the most recent copy of the analysis.
C. Storm water runoff primarily discharges to (check only one):
[ ] Surface water
[ ] Seeps into the ground
[ ] Municipal storm sewer
D. This general permit requires the development and implementation of a Best Management Practice (BMP) Plan. Does
the facility have a BMP Plan? [ ] Yes
[ ] No
E. Does the facility have any of the following other control measures to prevent pollution?
1. Structural control measures (basins, etc.)
[ ] Yes
[ ] No
2. Treatment of groundwater (retention, aeration)
[ ] Yes
[ ] No
3. Other. If so, please describe:
F. Are there any known impacts on the receiving water as a result of any discharges under DSN001? [ ] Yes
[ ] No
If YES, to what extent?
G. Were there any past industrial activities on the site that would contribute to storm water contamination?
[ ] Yes
[ ] No If YES, please explain:
H. Are any raw materials, finished products, waste products or chemicals exposed to storm water currently or in the last
three years? [ ] Yes
[ ] No
If YES, please list:
ADEM Form 383 10/17 m4
Page 3 of 13
I.
Does bulk material from bulk handling areas contaminate storm water? [ ] Yes
[ ] No
If YES, please describe:
J. Does this facility deal with live warm-blooded animals at any time? [ ] Yes
[ ] No
If YES, please contact the Industrial Section of ADEM’s Water Division before proceeding. The discharge of storm
water from industries that slaughter warm-blooded animals is no longer allowed under the NPDES General Permit No.
ALG150000.
ADEM Form 383 10/17 m4
Page 4 of 13
DSN003: 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 DSN003, 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 383 10/17 m4
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