Form 1 "General Information" - Montana

What Is Form 1?

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

Form Details:

  • Released on May 1, 2012;
  • The latest edition provided by the Montana 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 Form 1 by clicking the link below or browse more documents and templates provided by the Montana Department of Environmental Quality.

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Agency Use
Permit No.:
Date Rec’d
Amt Rec’d
Check No.
Rec’d By
WATER PROTECTION BUREAU
FORM
GENERAL INFORMATION
1
(See instructions before completing)
Section A –
Montana Pollutant Discharge Elimination System
MARK ‘X’
MARK ‘X’
SPECIFIC QUESTIONS
SPECIFIC QUESTIONS
FORM
FORM
YES
NO
YES
NO
ATTACHED
ATTACHED
1. Is this facility a publicly owned treatment works
2. Does or will this facility (either existing or
which results in a discharge to state surface waters
proposed) include a concentrated animal
or waters of the U.S.? (FORM 2A)
feeding operation or aquatic animal
production facility which results in a
discharge to state surface waters or waters of
the U.S.? (FORM 2B)
3. Is this a facility which currently results in a
4. Is this a proposed facility (other than those
discharge of industrial wastewater to state surface
described in 1 or 2 above) which will result
water other than those described in 1 or 2 above?
in a discharge of industrial wastewater to
(FORM 2C)
state surface waters? (FORM 2D)
5. Does this facility discharge only non-process
6. Does this facility discharge or propose to
wastewater, not subject to federal effluent
discharge storm water associated with
guidelines or new source performance standards to
industrial activity either alone or in
state surface waters? (FORM 2E)
combination with non-storm water
discharges? (FORM 2F)
Montana Ground Water Pollution Control System (MGWPCS)
7. Does this facility discharge sewage to ground water
8. Does this facility discharge industrial wastes,
through infiltration, percolation or other methods
or other wastes, to ground water through
of subsurface disposal? (GW-1)
infiltration, percolation, or other methods of
subsurface disposal? (GW-2)
Section B – Facility or Activity Information
Facility Name
Facility Location
City, State, Zip
Telephone Number ______________________
County: _________________________________________
Township: _________________ Range: _____________ Section: ____________ ; ______1/4 ______1/4 _____1/4
Latitude:
Longitude:
Is the facility located on Indian lands?
YES
NO
Section C – Facility Contact
Facility Contact Name/Title
Mailing Address
City, State, Zip
Email
Telephone Number
Version 1.2
Revised 5/12
Page 1 of 4
Agency Use
Permit No.:
Date Rec’d
Amt Rec’d
Check No.
Rec’d By
WATER PROTECTION BUREAU
FORM
GENERAL INFORMATION
1
(See instructions before completing)
Section A –
Montana Pollutant Discharge Elimination System
MARK ‘X’
MARK ‘X’
SPECIFIC QUESTIONS
SPECIFIC QUESTIONS
FORM
FORM
YES
NO
YES
NO
ATTACHED
ATTACHED
1. Is this facility a publicly owned treatment works
2. Does or will this facility (either existing or
which results in a discharge to state surface waters
proposed) include a concentrated animal
or waters of the U.S.? (FORM 2A)
feeding operation or aquatic animal
production facility which results in a
discharge to state surface waters or waters of
the U.S.? (FORM 2B)
3. Is this a facility which currently results in a
4. Is this a proposed facility (other than those
discharge of industrial wastewater to state surface
described in 1 or 2 above) which will result
water other than those described in 1 or 2 above?
in a discharge of industrial wastewater to
(FORM 2C)
state surface waters? (FORM 2D)
5. Does this facility discharge only non-process
6. Does this facility discharge or propose to
wastewater, not subject to federal effluent
discharge storm water associated with
guidelines or new source performance standards to
industrial activity either alone or in
state surface waters? (FORM 2E)
combination with non-storm water
discharges? (FORM 2F)
Montana Ground Water Pollution Control System (MGWPCS)
7. Does this facility discharge sewage to ground water
8. Does this facility discharge industrial wastes,
through infiltration, percolation or other methods
or other wastes, to ground water through
of subsurface disposal? (GW-1)
infiltration, percolation, or other methods of
subsurface disposal? (GW-2)
Section B – Facility or Activity Information
Facility Name
Facility Location
City, State, Zip
Telephone Number ______________________
County: _________________________________________
Township: _________________ Range: _____________ Section: ____________ ; ______1/4 ______1/4 _____1/4
Latitude:
Longitude:
Is the facility located on Indian lands?
YES
NO
Section C – Facility Contact
Facility Contact Name/Title
Mailing Address
City, State, Zip
Email
Telephone Number
Version 1.2
Revised 5/12
Page 1 of 4
Section D – Existing or Pending Permits, Certifications, or Approvals
MPDES Permit
404 Permit (dredge & fill)
UIC #
MGWPCS #
Plat Approval EQ #
Other
(provide a brief description)
Section E – Nature of Business
(4-digit, in order of priority)
SIC CODES
Code
Code
A. First
B. Second
1
2
| | |
| | |
Code
Code
C. Third
D. Fourth
3
4
| | |
| | |
Attach to this application a topographic map of the area extending to at least one mile beyond property boundaries. The
MAP:
map must show the outline of the facility, the location of each of its existing and proposed intake and discharge structures (outfalls),
each of its hazardous waste treatment, storage, or disposal facilities, and each well where it injects fluids underground. Include all
springs, rivers and other surface water bodies in the map area.
Section F – Applicant (Owner/Operator) Information
Applicant (Operator) Name
Mailing Address
City, State, Zip
Telephone Numbers __________________________
Is the ‘Operator’ listed above also the owner?
YES
NO
Status of Applicant (Check One)
Federal
State
Private
Public
Other
(specify)
CERTIFICATION
Section G – Applicant Information: This application must be completed, signed, and certified as follows:
For a corporation, by a principal officer of at least the level of vice president;
For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or
For a municipality, state, federal, or other public facility, by either a principal executive officer or ranking
elected official.
All Applicants Must Complete the Following 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 persons who manage the system or those persons directly responsible for gathering the information, it 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 violation.
A. Name and Official Title (Type or Print)
B. Phone No.
C. Signature
D. Date Signed
Version 1.2
Revised 5/12
Page 2 of 4
INSTRUCTIONS FOR
Form 1 – GENERAL INFORMATION
Who Must Apply?
Except as provided in 75-5-401(5), MCA, the Montana Water Quality Act (MWQA) prohibits any of the following
activities without a valid permit from the Department:
1) construct, modify or operate a disposal system that discharges to any state waters;
2) construct or use any outlet for the discharge of sewage, industrial wastes that discharges into any state waters or;
3) discharge sewage, industrial or other wastes into any state waters.
State waters includes any body of water, either on the surface or underground (ground water) and includes irrigation
systems, drainage systems, ephemeral and intermittent drainage ways. Treatment works used to collect, treat,
transport, or impound pollutants are not state waters.
Do not leave blank spaces; if a question does not apply, put “NA” in the space provided. Please type or print
legibly; applications that are not legible will be returned.
Section A – Additional Forms:
Complete Section A (Items 1- 8) to determine which additional forms must be submitted to the Department. If you
answer ‘yes’ to any questions, you must submit this form and the supplemental form listed in the parentheses
following the question. Mark ‘X’ in the box in the third column if the supplemental form is attached.
Section B – Facility Information:
Give the facility’s official or legal name. Do not use a colloquial name. The facility name means the building,
structure (manufacturing, commercial or residential), process, source, or physical site, from which pollutants or
wastes are, or will be, collected, generated, stored, treated (treatment works) or discharged (disposal system). The
facility may be public or privately owned property, such as, a manufacturing plant, municipal wastewater treatment
plant, animal feeding operation or community drain field. Give the address or location of this facility and the most
accurate geographic information; latitude and longitude must be accurate to nearest 15 seconds. See ARM
17.30.1304, ARM 17.30.1001(13) or 75-5-103(24), MCA. Geographic information may be obtained at
http://nris.state.mt.us
Section C – Facility Contact:
Give the name, title and work telephone number of a person who is thoroughly familiar with the operation of the
facility and with the facts reported in this application and who can be contacted by the Department for additional
information if necessary.
Section D – Existing or Pending Permits, Certifications, or Approvals
Give the permit or approval number for all permits, including general permits that have been issued to the facility,
including those permit or approvals which have not been issued.
Section E – Nature of Business:
Provide a brief description of the nature of the business (e.g., products produced or services provided).
SIC Codes: List, in descending order of significance, the four 4-digit standard industrial classification (SIC) codes
which best describe your facility in terms of the principal products or services you produce or provide. Also,
provide a brief description in the space provided. Applicants are encouraged to consult the Standard Industrial
Classification Manual for a complete listing of SIC Codes. Copies of the Manual are available through the
Government Printing Office in Washington D.C., or on-line at:
http://www.osha.gov/pls/imis/sicsearch.html
MAP: Maps & well locations may be obtained at
http://nris.state.mt.us
. Provide a topographic map or maps of the
area extending at least one mile beyond the property boundaries of the facility which clearly show the following: the
legal boundaries of the facility; the location and serial number of each of your existing and proposed intake and
discharge structures; all hazardous waste management facilities; each well where you inject fluids underground; and
all springs and surface water bodies in the area, plus all drinking water wells within ¼ mile of the facility which are
identified in the public record or otherwise known to you.
If an intake or discharge structure, hazardous waste disposal site, or injection well associated with the facility is
located more than one mile from the plant, include it on the map, if possible. If not, attach additional sheets
Version 1.2
Revised 5/12
Page 3 of 4
describing the location of the structure, disposal site, or well, and identify the U.S. Geological Survey (or other)
map corresponding to the location.
Section F – Applicant (Owner/Operator) Information:
Give the name, as it is legally referred to, of the person, business, public organization, or other entity that owns or
operates the facility described in Section B of this application. The operator is the legal entity which controls the
facility’s operation. The permit will be issued to the entity identified in this section (Section F). The
owner/operator is the entity which is responsible for compliance with the permit, statute and applicable regulations.
Section G – Certification:
This form must be signed and certified by the appropriate official as given in Section G and ARM 17.30.1323. The
Montana Water Quality Act provides for penalties of not more than $25,000 or imprisonment for not more than 6
months, or both, for any person that knowingly make a false statement, representation, or certification in any
application, record, report, plan or other document filed or required to be maintained by the Act, or who falsifies,
tampers with, or knowingly renders inaccurate any monitoring device or method required under the Act. 75-5-633,
MCA.
Fees:
The MWQA requires that the Department collect fees sufficient to cover the cost of issuing permits as well as the
administrative costs associated with these activities. The Department collects both application and annual fees.
Fees vary depending upon the complexity, type and strength of wastewater and the number of discharge points. Fee
information is available on the Departments’ website:
www.deq.mt.gov
or by contacting the Water Protection
Bureau at (406) 444-3080. The Department will not process this application until all of the requested information is
supplied, the application is complete, and the appropriate fees are paid. Return this application form [Form 1] and
any supplemental forms, and fee to:
Department of Environmental Quality
Water Protection Bureau
PO Box 200901
Helena MT 59620-0901
Version 1.2
Revised 5/12
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