Form GW-2 "Ground Water Pollution Control System (Mgwpcs) Industrial & Other Wastewater - Permit Application" - Montana

What Is Form GW-2?

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.

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Download Form GW-2 "Ground Water Pollution Control System (Mgwpcs) Industrial & Other Wastewater - Permit Application" - Montana

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Page background image
Agency Use
Permit No.:
Date Rec’d
Rec’d By
WATER PROTECTION BUREAU
FORM
Ground Water Pollution Control System (
)
MGWPCS
GW-2
Industrial & Other Wastewater - Permit Application
This form must be accompanied by DEQ Form 1. Form GW-2 is to be used for facilities that discharge or propose to discharge waste
from the process of business or industry or the development of any natural resource together with any sewage that may be present
(industrial waste) or other waste, and fulfills the requirements of ARM 17.30.1023(4). Please read the attached instructions before
completing this application. Do not leave blank spaces; if a question is not applicable put an ‘NA’ in the space provided. You must
print or type legibly; applications that are not legible will be returned.
Section A – Facility/Site Information
(Must be the same as Form 1)
Facility Name
Facility Location
Facility Contact / Title
Mailing Address
City, State, Zip
Telephone Number(s)
Vicinity Map:
The following information must be clearly labeled on a project vicinity map attached to this application. Please identify
location and name of adjacent surface water, location and ownership of water supply wells, springs, and other ground water
intake structures within 1 mile of the proposed or existing source(s).
Facility Site Plan:
Attach to this application a Facility Site Plan drawing(s) showing the topography of the area extending at least to the
property lines of the facility. The map must show the outline of buildings, structures, parking areas, north arrow, scale and
facilities directly pertinent to processes, structures and discharges to be covered by the permit that may be issued in
response to this application. At minimum, the location of each of the existing and proposed structures must be clearly
labeled on the map including but not limited to: wastewater collection and conveyance structures, wastewater treatment
facilities, wastewater disposal structures/systems, and monitoring or supply well location(s). The required information must
be clearly labeled on the Facility Site Plan. For facilities that cover larger land areas, specific portions of the Facility Plan
may be included on separate drawing(s) at a smaller scale to provide necessary detail.
Section B – Application and Source Status
(Check all applicable boxes.)
Application Status
Source Status
New, no existing GWPCS Permit
New or Proposed
Permit Renewal
Existing Source
Permit Modification
Other:
Other:
Version 1.1
Page 1 of 17
Agency Use
Permit No.:
Date Rec’d
Rec’d By
WATER PROTECTION BUREAU
FORM
Ground Water Pollution Control System (
)
MGWPCS
GW-2
Industrial & Other Wastewater - Permit Application
This form must be accompanied by DEQ Form 1. Form GW-2 is to be used for facilities that discharge or propose to discharge waste
from the process of business or industry or the development of any natural resource together with any sewage that may be present
(industrial waste) or other waste, and fulfills the requirements of ARM 17.30.1023(4). Please read the attached instructions before
completing this application. Do not leave blank spaces; if a question is not applicable put an ‘NA’ in the space provided. You must
print or type legibly; applications that are not legible will be returned.
Section A – Facility/Site Information
(Must be the same as Form 1)
Facility Name
Facility Location
Facility Contact / Title
Mailing Address
City, State, Zip
Telephone Number(s)
Vicinity Map:
The following information must be clearly labeled on a project vicinity map attached to this application. Please identify
location and name of adjacent surface water, location and ownership of water supply wells, springs, and other ground water
intake structures within 1 mile of the proposed or existing source(s).
Facility Site Plan:
Attach to this application a Facility Site Plan drawing(s) showing the topography of the area extending at least to the
property lines of the facility. The map must show the outline of buildings, structures, parking areas, north arrow, scale and
facilities directly pertinent to processes, structures and discharges to be covered by the permit that may be issued in
response to this application. At minimum, the location of each of the existing and proposed structures must be clearly
labeled on the map including but not limited to: wastewater collection and conveyance structures, wastewater treatment
facilities, wastewater disposal structures/systems, and monitoring or supply well location(s). The required information must
be clearly labeled on the Facility Site Plan. For facilities that cover larger land areas, specific portions of the Facility Plan
may be included on separate drawing(s) at a smaller scale to provide necessary detail.
Section B – Application and Source Status
(Check all applicable boxes.)
Application Status
Source Status
New, no existing GWPCS Permit
New or Proposed
Permit Renewal
Existing Source
Permit Modification
Other:
Other:
Version 1.1
Page 1 of 17
Section C – Outfall Location
For each outfall, provide the latitude and longitude, and method of wastewater disposal system
.
(See Section K)
Longitude
Outfall
Latitude
Method of Disposal
Number
Deg
Min
Sec
Deg
Min
Sec
(list)
001
002
Section D – Collection System Information
For each outfall list all operations contributing wastewater to the effluent stream, including process wastewater, sanitary wastewater,
cooling water and stormwater runoff (i.e. stormwater, floor drains, sump collection, sanitary sewer, process wastewater, other ).
Operation(s) Contributing Flow
Average Daily
Maximum
Outfall #
Average Annual
Operation
(list)
Flow
Daily Flow
% Contribution
(include units)
(include units)
001
002
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Section E – Treatment System Capacity
For new treatment works, provide hydraulic design capacity information; for existing systems, provide both design and measured
information.
Measured Flow
Design Capacity
Two Years Ago
Last Year
This Year
Average Daily Flow, gpd
Maximum Daily Flow, gpd
Flow Measurement Device(s):
Manufacturer:
Type:
Section F - Treatment System Description
(Describe the treatment system(s) or best management practices (BMP’s) used to reduce pollutants. Attach additional sheets if
necessary.)
Line Drawing:
Attach a line drawing showing water flow through the facility. Indicate sources of intake water, operations contributing wastewater to
the effluent, any process water or waste holding ponds or impoundments and treatment units labeled to correspond to the more detailed
descriptions in Section F. Construct a water balance on the line drawing showing design flow between intakes, operations, treatment
units, flow measurement location(s), sampling locations and outfalls. If a water balance cannot be determined, provide a pictorial
description of the nature and amount of any sources of water and any collection or treatment measures.
Scheduled Improvements and Schedules of Implementation.
Provide information on any uncompleted implementation schedule or uncompleted plans for improvements that will affect
the wastewater treatment, effluent quality or design capacity of the treatment works.
Yes
No Are planned improvements or implementation schedule required by local, state or federal
agencies?
List the outfall number for each outfall that is covered by this implementation schedule:
Version 1.1
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Section G – Process Water or Waste Holding Ponds/Impoundments
Type/Purpose:
Total Capacity:
Units
Dimension: Length
Units
Width
Units
Design Depth:
Units
Detention Time:
Units
Liner Type:
Liner Specification:
Material:
Thickness:
Units
Permeability:
Units
Depth to ground water from bottom of excavation:
Units
Emergency overflow structure:
Yes
No
Leak Detection System:
Yes
No
Describe:
Other Information:
Attach the results of any seepage tests that have been conducted for this facility:
Section H – Engineering Report(s)
A. If there is any technical evaluation concerning your wastewater collection & treatment, including engineering reports
or pilot plant studies, check the appropriate box below.
Report Available, copy attached
No Report
B. Provide the name and location of any existing facilities which, to the best of your knowledge, resembles this
production facility with respect to production processes, wastewater constituents, or wastewater collection & treatment.
Name:
Location:
C. Other Information
(Use the space below to expand upon any of the above questions or to bring to the attention of the reviewer any other information
you feel should be considered in establishing permit limitations for the proposed facility. Attach additional sheets if necessary.)
Version 1.1
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Section I – Chemical Additions
List all chemical(s), product(s) used in industrial process or facility maintenance. Attach additional pages where necessary. Submit a
complete list of chemicals; include products used even on a temporary basis (Material Safety Data Sheets – MSDS – may be submitted
in addition to the list).
Name(s):
Name(s):
Manufacture(s):
Manufacture(s):
Name(s):
Name(s):
Manufacture(s):
Manufacture(s):
Name(s):
Name(s):
Manufacture(s):
Manufacture(s):
Section J – Sludge
Identify transporter and treatment works facility responsible for sludge removal and/or treatment. If sludge is not removed from
facilty, identify means of disposal.
Transporter
Treatment works facility
Name
Name
Address
Address
Telephone
Telephone
Sludge Disposal
Indicate the method(s) used for disposal of sludge generated during wastewater treatment.
Composting Facility
Land application
Disposal at WWTP
Landfill (Municipal, Hazardous Waste)
Other - Describe:
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