Form MO 780-2112 Form W - Concentrated Animal Feeding Operation (Cafo) Operating Permit Application - Water Protection Program - Missouri

Form MO780-2112 is a Missouri Department of Natural Resources form also known as the "Form W - Concentrated Animal Feeding Operation (cafo) Operating Permit Application - Water Protection Program". The latest edition of the form was released in July 1, 2014 and is available for digital filing.

Download an up-to-date Form MO780-2112 in PDF-format down below or look it up on the Missouri Department of Natural Resources Forms website.

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
WATER PROTECTION PROGRAM
CHECK NUMBER:
FORM W - CONCENTRATED ANIMAL FEEDING OPERATION
DATE RECEIVED
FEE SUBMITTED
(CAFO) OPERATING PERMIT APPLICATION
Complete all applicable sections. Instructions for completing the form are located at the end of the form. Sign, date and return the form and
all requested documents along with a check for the appropriate permit fee to the Missouri Department of Natural Resources. Make a copy of
this completed form and keep it with your nutrient management plan.
PART 1 – PERMIT OWNERSHIP AND CONTACT INFORMATION
1. 1 OPERATION NAME
CURRENT PERMIT NUMBER
COUNTY
MO-
PHYSICAL ADDRESS
LEGAL DESCRIPTION
TELEPHONE NUMBER WITH AREA CODE
Sec.:
Twn.:
Rng.:
CITY
STATE
ZIP CODE
1.2 OWNER (PROVIDE LEGAL NAME)
EMAIL ADDRESS
MAILING ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
1.3 CONTINUING AUTHORITY (IF DIFFERENT THAN THE OWNER)
MAILING ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
PART 2 – PERMIT TYPE AND PERMIT ACTION
2.1 PERMIT TYPE
2.2 PERMIT ACTION*
NPDES Site Specific Permit
New Permit
Renewal
Request review of draft permit prior to public notice.
Yes
No
Modification
Ownership Transfer
________________________________________
PREVIOUS OWNERS NAME
________________________________________
NPDES General Permit (MOG01)
ADRESS
________________________________________
CITY
STATE
ZIP CODE
________________________________________
State No-Discharge General Permit (MOGS1)
SIGNATURE
DATE
.
*See instructions for additional requirements and documents for the request permit action
PART 3 – DESIGN CAPACITY FOR MANURE STORAGE AND ANIMALS OF EACH CAFO FEATURE
3.1 STORAGE STRUCTURE TYPES, AMOUNT OF STORAGE, AND AMOUNT OF MANURE GENERATED PER YEAR.
List All Manure Storage Structures at each CAFO Feature
Dry Manure Handling System
Wet Manure Handling System
CAFO
Design Dry Process
Days of
Total Storage
Design Wastewater
Days of
Design
Storage Structure Type(s)
Feature
Waste (tons/yr.)
Storage
Capacity (gal)
per Year (gal./yr.)
Storage
Flow MGD
001
002
003
004
005
3.2 LIST EACH TYPE OF ANIMAL IN CONFINEMENT AND THE NUMBER OF EACH ANIMAL TYPE.
CAFO
Animal
Animal
Animal
Animal Category #1
Animal Category #2
Animal Category #3
Feature
Numbers
Numbers
Numbers
001
002
003
004
005
PART 4 – OPERATIONAL INFORMATION
4.1 OPERATIONAL INFORMATION (SEE INSTRUCTIONS)
SIC Code(s)
CAFO Class Size
4.2 Is this an export-only operation?
Yes
No
MO 780-2112 (07-14)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR OFFICE USE ONLY
WATER PROTECTION PROGRAM
CHECK NUMBER:
FORM W - CONCENTRATED ANIMAL FEEDING OPERATION
DATE RECEIVED
FEE SUBMITTED
(CAFO) OPERATING PERMIT APPLICATION
Complete all applicable sections. Instructions for completing the form are located at the end of the form. Sign, date and return the form and
all requested documents along with a check for the appropriate permit fee to the Missouri Department of Natural Resources. Make a copy of
this completed form and keep it with your nutrient management plan.
PART 1 – PERMIT OWNERSHIP AND CONTACT INFORMATION
1. 1 OPERATION NAME
CURRENT PERMIT NUMBER
COUNTY
MO-
PHYSICAL ADDRESS
LEGAL DESCRIPTION
TELEPHONE NUMBER WITH AREA CODE
Sec.:
Twn.:
Rng.:
CITY
STATE
ZIP CODE
1.2 OWNER (PROVIDE LEGAL NAME)
EMAIL ADDRESS
MAILING ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
1.3 CONTINUING AUTHORITY (IF DIFFERENT THAN THE OWNER)
MAILING ADDRESS
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
PART 2 – PERMIT TYPE AND PERMIT ACTION
2.1 PERMIT TYPE
2.2 PERMIT ACTION*
NPDES Site Specific Permit
New Permit
Renewal
Request review of draft permit prior to public notice.
Yes
No
Modification
Ownership Transfer
________________________________________
PREVIOUS OWNERS NAME
________________________________________
NPDES General Permit (MOG01)
ADRESS
________________________________________
CITY
STATE
ZIP CODE
________________________________________
State No-Discharge General Permit (MOGS1)
SIGNATURE
DATE
.
*See instructions for additional requirements and documents for the request permit action
PART 3 – DESIGN CAPACITY FOR MANURE STORAGE AND ANIMALS OF EACH CAFO FEATURE
3.1 STORAGE STRUCTURE TYPES, AMOUNT OF STORAGE, AND AMOUNT OF MANURE GENERATED PER YEAR.
List All Manure Storage Structures at each CAFO Feature
Dry Manure Handling System
Wet Manure Handling System
CAFO
Design Dry Process
Days of
Total Storage
Design Wastewater
Days of
Design
Storage Structure Type(s)
Feature
Waste (tons/yr.)
Storage
Capacity (gal)
per Year (gal./yr.)
Storage
Flow MGD
001
002
003
004
005
3.2 LIST EACH TYPE OF ANIMAL IN CONFINEMENT AND THE NUMBER OF EACH ANIMAL TYPE.
CAFO
Animal
Animal
Animal
Animal Category #1
Animal Category #2
Animal Category #3
Feature
Numbers
Numbers
Numbers
001
002
003
004
005
PART 4 – OPERATIONAL INFORMATION
4.1 OPERATIONAL INFORMATION (SEE INSTRUCTIONS)
SIC Code(s)
CAFO Class Size
4.2 Is this an export-only operation?
Yes
No
MO 780-2112 (07-14)
Completing PARTS 5 - 11 will meet the requirements of a Nutrient Management Plan (NMP) for an export only operation.
PART 5 – MANURE STORAGE
5.1 Do all manure storage structures have adequate storage, and operated and maintained as no discharge?
Yes
No
PART 6 – ANIMAL MORTALITY
.
6.1 PEMANENT METHOD OF DISPOSING OF ROUTINE ANIMAL MORTALITIES
Composting
Rendering
Send to a Landfill
Incineration
Other (Describe)
6.2 DESCRIBE METHOD OF MORTALITY HANDLING AND STORAGE THROUGH ALL PHASES TO FINAL DISPOSAL. (EXAMPLE: MORTALITIES ARE COMPOSTED WITHIN 24 HOURS OF DEATH
AND FINISHED COMPOST PRODUCT IS STORED UNDER ROOF UNTIL LAND APPLIED). ALSO DESCRIBE THE TYPE OF COMPOST STRUCTURE USED, IF APPLICABLE.
PART 7 – DIVERSION OF CLEAN WATER
7.1 Is clean stormwater diverted from the production area?
Yes
No
7.2 IF YES, DESCRIBE CONTROLS AND MEASURES USED TO DIVERT STORMWATER.
7.3 IF NO, DESCRIBE HOW CONTAMINATED STORMWATER IS CONTAINED AND INCLUDE THE STORAGE CAPACITY OF THE CONTAINMENT IF NOT PREVIOUSLY PROVIDED.
PART 8 – PREVENT DIRECT CONTACT OF ANIMALS WITH SURFACE WATERS
8.1 Do the animals have access to waters of the state within the production area?
Yes
No
8.2 LIST MEASURES USED TO PREVENT CONFINED ANIMAL FORM HAVING DIRECT CONTACT WITH WATERS OF THE STATE.
PART 9 – CHEMICAL HANDLING
Check the appropriate boxed below to indicate method for handling and disposal of chemicals used by the operation:
9.1
Chemicals are stored, handled, and disposed of according to manufacturer labels.
Chemical storage and handling areas are protected from precipitation and runoff, and any spillage is contained within these areas.
Emergency procedures and equipment are in place to contain and clean up chemical spills.
Equipment wash areas are designed and constructed to prevent contamination of surface waters.
No chemicals are stored or handled in the production area.
PART 10 – MANURE ANALYSIS TESTING
10.1 LIST EACH TYPE OF MANURE SOURCE. (i. e. MANURE, LITTER, COMPOST, WASTE WATER.)
10.2 DESCRIBE PROCEDURES FOR ENSURING EACH MANURE SOURCE IS TESTED ANNUALLY.
PART 11 – RECORD KEEPING
11.1 Are records of all inspections, manure transfers, discharges and land application maintained?
Yes
No
PART 12 – SIGNATURE
NAME
TITLE
SIGNATURE
DATE
Part 13 - Engineer Certification
House Bill 28, which became effective Aug 28, 2013, contained provisions that changed construction permitting requirements. Construction
permits are required for the construction of an earthen storage structure to hold, convey, contain, store, or treat domestic, agricultural, or
industrial process wastewater. Construction of all other point source systems designed to hold, convey, contain, store, or treat domestic,
agricultural, or industrial process waste must be designed by a professional engineer registered in Missouri in accordance with design
regulations.
Operation Name
Engineer Firm
Address
Address
City
City State Zip Code
ENGINEER SEAL
I, Project Engineer, certify that above described systems have
been designed in accordance with Missouri CAFO design
regulations in 10 CSR 20-8.300
PROJECT ENGINEER SIGNATURE
MO 780-2112 (07-14)
LAND APPLICATION INFORMATION TABLE (REQUIRED FOR NPDES PERMTS ONLY)
Operation Name:
Class Size:
Permit #:
County:
1
Crop #1
Crop #2
Crop #3
Crop #4
Crop #5
N or P
Legal
Spreadable
P Loss
Based
Yield
Yield
Yield
Yield
Yield
2
3
3
3
3
3
Field Name
Description
Acres
Risk
Application
Crop
Goal
Crop
Goal
Crop
Goal
Crop
Goal
Crop
Goal
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
Sec.
Twn.
Rng.
1
If more than five planned or alternative crops per field continue on next line.
2
Soil Test P Rating or P Index Rating may be used.
3
Express yield in Bu=Bushels or T=Tons per acre.
THIS PAGE WAS INTENTIONALLY LEFT BLANK
INSTRUCTIONS
PART 1 - PERMIT OWNERSHIP AND CONTACT INFORMATION
1.1 General location and contact information for the operation. Do not use P.O. Box or RR as physical address of the operation.
1.2 Provide the name of the legal entity that owns or operates the CAFO facility.
1.3 List the Continuing Authority, if it is the same as the Owner enter “Same as above”. The Continuing Authority is the permanent
organization or party, responsible for operation and maintenance of the CAFO. All corporate entities are to be listed with the
Secretary of State’s web site.
PART 2 - PERMIT TYPE
2.1 Check only one box. Indicate which permit you are applying for. EPA regulations require CAFO’s that discharge to obtain a
NPDES (general or site specific) permit. State Regulations require all Class I CAFO’s that do not seek coverage under a NPDES
permit to obtain a State No-Discharge General Permit.
2.2 Indicate which type of permit action is being requested. Application for NPDES permit must also complete Land Application
Information Table.
Applications for new permits or permit modification the following additional documents must be submitted:
Title page of engineering documents or similar document. This must include name and address of the operation, date prepared,
name and address of firm preparing the report, seal and signature of the engineer, and a statement indicating the project was
designed in accordance with 10 CSR 20-8.300.
Narrative project summary. This shall include the number of confinement buildings, the design capacity in animal units and
animal numbers for each type of animal, and an explanation of the manure management system and any proposed
modifications.
Calculations showing the amount of manure generated annually, storage volume calculations and days of storage of all manure
storage structures, including mortality composter.
An aerial and topographic map showing the extent of the production area including all confinement buildings, open lots, manure
storage structures surface water and areas subject to a one hundred year flood event within or adjacent to the production area,
and production area setback distances in accordance with 10 CSR 20-8.300(5)(B).
Nutrient Management Plan. NPDES permit applications for a new or modified permit shall include the operations nutrient
management plan. For State no-discharge permit applications for a new permit shall include the operations nutrient
management plan. If the operation is export only, completing Parts 5-11 meets this requirement.
Class I CAFOs shall also include proof of neighbor notice to all parties listed in 10 CSR 20-6.300(3)(C)2, maps that meets the
requirement of 10 CSR 20-6.300(3)(C)4.
Applications for renewal of a NPDES permit shall include the NMP.
Ownership transfers must have previous owner name, address and signature.
PART 3 – DESIGN CAPACITY FOR MANURE STORAGE AND ANIMALS OF EACH CAFO FEATURE
Some of this information can be obtained from your current operating permit or construction permit if one was required.
3.1 From the table below enter the code for each storage structure type for a new permit. For renewal or modification enter the code
for each storage structure type for each CAFO Feature listed on the permit. If there are multiple storage types at a CAFO Feature,
use a comma to separate the code and days of storage. The Design Liquid Flow is only needed for NPDES permits, to calculate,
divide the Design Wastewater per year by 365, and then divide by one million. (e.g. for a Design Wastewater per Year of 5,000,000
gal., 5,000,000÷365 = 13,698.6 gal/day, then 13,698.6÷1,000,000 = .0136986 MGD). Attach additional sheets if necessary.
Code
Storage Structure Type
Code
Storage Structure Type
A
Above Ground Storage Tank
F
Roofed Storage Shed
B
Below Ground Storage Tank
G
Mortality Composter
C
Underfloor (Deep ) Pits
H
Anaerobic Digestor
D
Storage Lagoon
I
Concrete Pad
E
Anaerobic Lagoon
J
Impervious Soil Pad
3.2 Per instructions in 3.1, enter the code from the table below for each animal category and the number of each animal type in
confinement. Do not include animals in pasture.
Code
Code
Animal Category
Animal Category
Beef/feeder cattle, veal calves, cow/calf pairs,
1
7
Chicken laying hens and broilers with wet handling system
dairy heifers
2
Horses
8
Chicken laying hens without wet handling system
3
Mature Dairy cows
9
Turkeys in growout phase
4
Swine under 55 lbs.
Chicken broilers, pullets and turkey poults in brood phase all
10
without wet handling system
5
Swine over 55 lbs.
Other (specify) Contact the Water Protection Program for
6
Sheep, lambs, meat & dairy goats
11
Animal Equivalent Units and SIC Codes for other animal types.

Download Form MO 780-2112 Form W - Concentrated Animal Feeding Operation (Cafo) Operating Permit Application - Water Protection Program - Missouri

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