ADEQ Form 2C "Application for Permit to Discharge Non-domestic Wastewater by Industrial and Commercial Operations" - Arizona

What Is ADEQ Form 2C?

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

Form Details:

  • Released on June 1, 2015;
  • The latest edition provided by the Arizona Department of Environmental Quality;
  • 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 ADEQ Form 2C by clicking the link below or browse more documents and templates provided by the Arizona Department of Environmental Quality.

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Download ADEQ Form 2C "Application for Permit to Discharge Non-domestic Wastewater by Industrial and Commercial Operations" - Arizona

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Arizona Dept. of Environmental Quality
AZPDES APPLICATION
AZPDES Individual Permits / Water Permits Section
FORM 2C
1110 W. Washington Street
Phoenix, AZ 85007
APPLICATION FOR PERMIT TO DISCHARGE NON-DOMESTIC WASTEWATER
BY INDUSTRIAL AND COMMERCIAL OPERATIONS
Please print or type in the unshaded areas only
AZPDES (NPDES) Permit No ________________________
I. OUTFALL LOCATION
For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water.
LATITUDE
LONGITUDE
OUTFALL NUMBER
RECEIVING WATER (list)
(list)
DEG.
MIN.
SEC.
DEG.
MIN.
SEC.
II. FLOWS, SOURCES OF POLLUTION AND TREATMENT TECHNOLOGIES
A. Attach a line drawing showing the water flow through the facility. Indicate sources of intake water, operations contributing wastewater to the
effluent and treatment units labeled to correspond to the more detailed descriptions in Part II.B. Construct a water balance on the line drawing
by showing average flows between intakes, operations, treatment units and outfalls. If a water balance cannot be determined (e.g., for certain
mining activities), provide a pictorial description of the nature and amount of any sources of water and any collection or treatment measures.
B. For each outfall, provide a description of: (1) All operations contributing wastewater to the effluent, including process wastewater, sanitary
wastewater, cooling water and storm water; (2) The average flow contributed by each operation; and (3) The treatment received by the
wastewater. Continue on additional sheets if necessary.
2. OPERATION(S) CONTRIBUTING FLOW
3. TREATMENT
1. OUTFALL NUMBER
b. AVERAGE
(list)
b. LIST CODES
a. OPERATIONS (list))
FLOW
a. DESCRIPTION
FROM TABLE 2C.1
(include units
Page 1of 5
Form 2C - Part 1
June 2015
Arizona Dept. of Environmental Quality
AZPDES APPLICATION
AZPDES Individual Permits / Water Permits Section
FORM 2C
1110 W. Washington Street
Phoenix, AZ 85007
APPLICATION FOR PERMIT TO DISCHARGE NON-DOMESTIC WASTEWATER
BY INDUSTRIAL AND COMMERCIAL OPERATIONS
Please print or type in the unshaded areas only
AZPDES (NPDES) Permit No ________________________
I. OUTFALL LOCATION
For each outfall, list the latitude and longitude of its location to the nearest 15 seconds and the name of the receiving water.
LATITUDE
LONGITUDE
OUTFALL NUMBER
RECEIVING WATER (list)
(list)
DEG.
MIN.
SEC.
DEG.
MIN.
SEC.
II. FLOWS, SOURCES OF POLLUTION AND TREATMENT TECHNOLOGIES
A. Attach a line drawing showing the water flow through the facility. Indicate sources of intake water, operations contributing wastewater to the
effluent and treatment units labeled to correspond to the more detailed descriptions in Part II.B. Construct a water balance on the line drawing
by showing average flows between intakes, operations, treatment units and outfalls. If a water balance cannot be determined (e.g., for certain
mining activities), provide a pictorial description of the nature and amount of any sources of water and any collection or treatment measures.
B. For each outfall, provide a description of: (1) All operations contributing wastewater to the effluent, including process wastewater, sanitary
wastewater, cooling water and storm water; (2) The average flow contributed by each operation; and (3) The treatment received by the
wastewater. Continue on additional sheets if necessary.
2. OPERATION(S) CONTRIBUTING FLOW
3. TREATMENT
1. OUTFALL NUMBER
b. AVERAGE
(list)
b. LIST CODES
a. OPERATIONS (list))
FLOW
a. DESCRIPTION
FROM TABLE 2C.1
(include units
Page 1of 5
Form 2C - Part 1
June 2015
C. Except for storm runoff, leaks or spills, are any of the discharges described in Parts II.A or B intermittent or seasonal?
YES (complete the following table)
NO (go to Item III)
____
____
3. FREQUENCY
4. FLOW
2. OPERATION(S)
a. FLOW RATE
b. TOTAL VOLUME
a. DAYS
1. OUTFALL
b. MONTHS
(in mgd)
(specify with units)
CONTRIBUTING FLOW
PER
NUMBER (list)
PER YEAR
c. DURATION
(list)
WEEK
(specify
(in days)
2.
(specify
1. LONG
2. MAXIMUM
1. LONG
average)
MAXIMUM
average)
TERM AVG.
DAILY
TERM AVG.
DAILY
III. PRODUCTION
A. Does an effluent guideline limitation promulgated by EPA under Section 304 of the Clean Water Act apply to your facility?
YES (complete Part III.B)
____ NO (go to Item IV)
____
B. Are the limitations in the applicable effluent expressed in terms of production (or other measure of operation)?
____ YES (complete Part III.C)
____ NO (go to Item IV)
_
C. If you answered Ayes@ to Part III.B, list the quantity which represents an actual measurement of your level of production, expressed in the
terms and units used in the applicable effluent guideline and indicate the affected outfalls.
AVERAGE DAILY PRODUCTION
AFFECTED OUTFALLS
(list outfall numbers)
OPERATIONS, PRODUCT, MATERIAL, ETC.
QUANTITY PER DAY
UNITS OF MEASURE
(specify)
Page 2of 5
Form 2C - Part 1
June 2015
IV. IMPROVEMENTS
A. Are you now required by any federal, state or local authority to meet any implementation schedule for the construction, upgrading or operation
of wastewater treatment equipment or practices or any other environmental programs which affect the discharges described in this application?
This includes, but is not limited to: permit conditions, administrative or enforcement orders, enforcement compliance schedule letters,
stipulations, court orders and grant or loan conditions.
____ YES (complete the following table )
____ NO (go to Part IV.B)
2. AFFECTED OUTFALLS
4. FINAL COMPLIANCE DATE
1. IDENTIFICATION
OF CONDITION,
3. BRIEF DESCRIPTION OF PROJECT
OUTFALL
SOURCE OF
AGREEMENT, ETC.
REQUIRED
PROJECTED
NUMBER
DISCHARGE
B. OPTIONAL: You may attach additional sheets describing any additional water pollution control programs (or other environmental projects
which may affect your discharges) you now have underway or which you plan. Indicate whether each program is now underway or planned
and indicate your actual planned schedules for construction.
____ MARK AX@ IF DESCRIPTION OF ADDITIONAL CONTROL PROGRAMS IS ATTACHED.
V. INTAKE AND EFFLUENT CHARACTERISTICS
A, B, C, & D: See instructions before proceeding. NOTE: Parts V.A, V.B, V.C, and V.D are included in the AADDENDUM@ to Form 2C.
Complete one set of Parts V.A - V.D for each outfall. Annotate the outfall and AZPDES (NPDES) permit number in the space provided at the
bottom of each page.
E. Use the space below to list any of the pollutants listed in Table 2C.3 AToxic Pollutants and Hazardous Substances,@ which you know or
have reason to believe is discharged or may be discharged from any outfall. For every pollutant you list, briefly describe the reasons you
believe it to be present and report any analytical data in your possession.
1. POLLUTANT
2. SOURCE
1. POLLUTANT
2. SOURCE
Page 3of 5
Form 2C - Part 1
June 2015
VI. POTENTIAL DISCHARGES NOT COVERED BY ANALYSIS
Is any pollutant listed in Part V.C a substance or a component of a substance which you currently use or manufacture as an intermediate or
final product or byproduct?
____ YES (list all such pollutants below)
____ NO (go to Item VII)
VII. BIOLOGICAL TOXICITY TESTING DATA
Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made on any of your discharges
or on a receiving water in relation to your discharge within the last three years?
____ YES (identify the test(s) and describe their purposes below)
____ NO (go to Item VIII)
Page 4of 5
Form 2C - Part 1
June 2015
VIII. CONTRACT ANALYSIS INFORMATION
Were any of the analyses reported in Item V performed by a contract laboratory or consulting firm?
____ YES (list the name, address and phone number of and pollutants
____ NO (go to Item IX)
analyzed by, each such laboratory or firm below)
C. TELEPHONE
D. POLLUTANTS
A. NAME
B. ADDRESS
(phone and area
ANALYZED
code)
(list)
IX. CERTIFICATION
AI 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.@
A. NAME & OFFICIAL TITLE (type or print)
B. PHONE NO. (telephone and area code)
C. SIGNATURE
D. DATE SIGNED
Pursuant to A.R.S. § 41-1030:
(1) ADEQ shall not base a licensing decision, in whole or in part, on a requirement or condition not specifically authorized by statute or
rule. General authority in a statute does not authorize a requirement or condition unless a rule is made pursuant to it that specifically
authorizes the requirement or condition.
(2) Prohibited licensing decisions may be challenged in a private civil action. Relief may be awarded to the prevailing party against
ADEQ, including reasonable attorney fees, damages, and all fees associated with the license application.
(3) ADEQ employees may not intentionally or knowingly violate the requirement for specific licensing authority. Violation is cause for
disciplinary action or dismissal, pursuant to ADEQ’s adopted personnel policy. ADEQ employees are still afforded the immunity in
A.R.S. §§ 12-821.01 and 12-820.02.
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Form 2C - Part 1
June 2015
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