Form MO780-1512 (B) "Application for Operating Permit for Facilities That Receive Primarily Domestic Waste and Have a Design Flow Less Than or Equal to 100,000 Gallons Per Day" - Missouri

What Is Form MO780-1512 (B)?

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

Form Details:

  • Released on September 1, 2016;
  • The latest edition provided by the Missouri Department of Natural Resources;
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  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-1512 (B) by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-1512 (B) "Application for Operating Permit for Facilities That Receive Primarily Domestic Waste and Have a Design Flow Less Than or Equal to 100,000 Gallons Per Day" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR AGENCY USE ONLY
WATER PROTECTION PROGRAM
CHECK NUMBER
FORM B: APPLICATION FOR OPERATING PERMIT FOR FACILITIES THAT
RECEIVE PRIMARILY DOMESTIC WASTE AND HAVE A DESIGN FLOW LESS
DATE RECEIVED
FEE SUBMITTED
THAN OR EQUAL TO 100,000 GALLONS PER DAY
READ THE ACCOMPANYING INSTRUCTIONS BEFORE COMPLETING THIS FORM
1. THIS APPLICATION IS FOR:
An operating permit for a new or unpermitted facility.
Construction Permit #
(Include completed antidegradation review or request for antidegradation review, see instructions)
A new site-specific operating permit formerly general permit #MOG
A site-specific operating permit renewal:
Permit #MO-
Expiration Date
A site-specific operating permit modification:
Permit #MO-
Reason:
General permit (MOGD – Non POTWs discharging < 50,000 GPD or MOG823 – Land Application of Domestic Wastewater):
Permit #MO-
Expiration Date
Is the appropriate fee included with the application (see instructions for appropriate fee)?
YES
NO
1.1
2. FACILITY
NAME
TELEPHONE NUMBER WITH AREA CODE
ADDRESS (PHYSICAL)
CITY
STATE
ZIP CODE
Legal description:
¼,
¼,
¼, Sec.
, T
, R
County
2.1
UTM Coordinates Easting (X):
Northing (Y):
2.2
For Universal Transverse Mercator (UTM), Zone 15 North referenced to North American Datum 1983 (NAD83)
Name of receiving stream:
2.3
Number of outfalls:
Wastewater outfalls:
Stormwater outfalls:
Instream monitoring sites:
2.4
3. OWNER
NAME
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
Request review of draft permit prior to public notice?
YES
NO
3.1
Are you a publicly owned treatment works?
YES
NO
3.2
If yes, is the Financial Questionnaire attached?
YES
NO
Are you a privately owned treatment works?
YES
NO
3.3
Are you a privately owned treatment facility regulated by the Public Service Commission?
YES
NO
3.4
4. CONTINUING AUTHORITY: Permanent organization that will serve as the continuing authority for the operation,
maintenance and modernization of the facility.
NAME
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
If the continuing authority is different than the owner, include a copy of the contract agreement between the two parties and a
description of the responsibilities of both parties within the agreement.
5. OPERATOR
NAME
TITLE
CERTIFICATE NUMBER
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
6. FACILITY CONTACT
NAME
TITLE
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
MO 780-1512 (09-16)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR AGENCY USE ONLY
WATER PROTECTION PROGRAM
CHECK NUMBER
FORM B: APPLICATION FOR OPERATING PERMIT FOR FACILITIES THAT
RECEIVE PRIMARILY DOMESTIC WASTE AND HAVE A DESIGN FLOW LESS
DATE RECEIVED
FEE SUBMITTED
THAN OR EQUAL TO 100,000 GALLONS PER DAY
READ THE ACCOMPANYING INSTRUCTIONS BEFORE COMPLETING THIS FORM
1. THIS APPLICATION IS FOR:
An operating permit for a new or unpermitted facility.
Construction Permit #
(Include completed antidegradation review or request for antidegradation review, see instructions)
A new site-specific operating permit formerly general permit #MOG
A site-specific operating permit renewal:
Permit #MO-
Expiration Date
A site-specific operating permit modification:
Permit #MO-
Reason:
General permit (MOGD – Non POTWs discharging < 50,000 GPD or MOG823 – Land Application of Domestic Wastewater):
Permit #MO-
Expiration Date
Is the appropriate fee included with the application (see instructions for appropriate fee)?
YES
NO
1.1
2. FACILITY
NAME
TELEPHONE NUMBER WITH AREA CODE
ADDRESS (PHYSICAL)
CITY
STATE
ZIP CODE
Legal description:
¼,
¼,
¼, Sec.
, T
, R
County
2.1
UTM Coordinates Easting (X):
Northing (Y):
2.2
For Universal Transverse Mercator (UTM), Zone 15 North referenced to North American Datum 1983 (NAD83)
Name of receiving stream:
2.3
Number of outfalls:
Wastewater outfalls:
Stormwater outfalls:
Instream monitoring sites:
2.4
3. OWNER
NAME
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
Request review of draft permit prior to public notice?
YES
NO
3.1
Are you a publicly owned treatment works?
YES
NO
3.2
If yes, is the Financial Questionnaire attached?
YES
NO
Are you a privately owned treatment works?
YES
NO
3.3
Are you a privately owned treatment facility regulated by the Public Service Commission?
YES
NO
3.4
4. CONTINUING AUTHORITY: Permanent organization that will serve as the continuing authority for the operation,
maintenance and modernization of the facility.
NAME
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
If the continuing authority is different than the owner, include a copy of the contract agreement between the two parties and a
description of the responsibilities of both parties within the agreement.
5. OPERATOR
NAME
TITLE
CERTIFICATE NUMBER
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
6. FACILITY CONTACT
NAME
TITLE
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
MO 780-1512 (09-16)
7. DESCRIPTION OF FACILITY
7.1 Process Flow Diagram or Schematic: Provide a diagram showing the processes of the treatment plant. Show all of the
treatment units, including disinfection (e.g. – chlorination and dechlorination), influents, and outfalls. Specify where samples are
taken. Indicate any treatment process changes in the routing of wastewater during dry weather and peak wet weather. Include a
brief narrative description of the diagram.
Attach sheets as necessary.
7.2 Attach an aerial photograph or USGS topographic map showing the location of the facility and outfall.
MO 780-1512 (09-16)
8. ADDITIONAL FACILITY INFORMATION
Facility SIC code:
Discharge SIC code:
8.1
Number of people presently connected or population equivalent (P.E.)
Design P.E.
8.2
Connections to the facility:
8.3
Number of units presently connected:
Homes
Trailers
Apartments
Other (including industrial)
Number of commercial establishments:
Design flow:
Actual flow:
8.4
Will discharge be continuous through the year?
Yes
No
8.5
Discharge will occur during the following months:
How many days of the week will discharge occur?
Is industrial wastewater discharged to the facility?
Yes
No
8.6
If yes, attach a list of the industries that discharge to your facility
Does the facility accept or process leachate from landfills?
Yes
No
8.7
Is wastewater land applied?
Yes
No
8.8
If yes, is Form I attached?
Yes
No
Does the facility discharge to a losing stream or sinkhole?
Yes
No
8.9
Has a wasteload allocation study been completed for this facility?
Yes
No
8.10
9. LABORATORY CONTROL INFORMATION
LABORATORY WORK CONDUCTED BY PLANT PERSONNEL
Lab work conducted outside of plant.
Yes
No
Push-button or visual methods for simple test such as pH, settlable solids.
Yes
No
Additional procedures such as dissolved oxygen, chemical
oxygen demand, biological oxygen demand, titrations, solids, volatile content.
Yes
No
More advanced determinations such as BOD seeding procedures,
fecal coliform, nutrients, total oils, phenols, etc.
Yes
No
Highly sophisticated instrumentation, such as atomic absorption and gas chromatograph.
Yes
No
10. COLLECTION SYSTEM
Length of pipe in the sewer collection system?
Feet, or
Miles (either unit is appropriate)
10.1
Does significant infiltration occur in the collection system?
Yes
No
10.2
If yes, briefly explain any steps underway or planned to minimize inflow and infiltration:
11. BYPASSING
Does any bypassing occur in the collection system or at the treatment facility?
Yes
No
If yes, explain:
MO 780-1512 (09-16)
12. SLUDGE HANDLING, USE AND DISPOSAL
Is the sludge a hazardous waste as defined by 10 CSR 25?
Yes
No
12.1
Sludge production, including sludge received from others:
Design dry tons/year
Actual dry tons/year
12.2
Capacity of sludge holding structures:
12.3
Sludge storage provided:
cubic feet;
days of storage;
average percent solids of sludge;
No sludge storage is provided.
Sludge is stored in lagoon.
Type of Storage:
Holding tank
Building
12.4
Basin
Lagoon
Concrete Pad
Other (Describe)
Sludge Treatment:
12.5
Anaerobic Digester
Lagoon
Composting
Storage Tank
Aerobic Digester
Other (Attach description)
Lime Stabilization
Air or Heat Drying
Sludge Use or Disposal:
12.6
Land Application
Surface Disposal (Sludge Disposal Lagoon, Sludge held for more than two years)
Contract Hauler
Hauled to Another treatment facility
Incineration
Sludge Retained in Wastewater treatment lagoon
Solid waste landfill
Person responsible for hauling sludge to disposal facility:
12.7
By applicant
By others (complete below)
NAME
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON
TELEPHONE NUMBER WITH AREA CODE
PERMIT NO.
MO-
Sludge use or disposal facility
12.8
By applicant
By others (Complete below.)
NAME
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON
TELEPHONE NUMBER WITH AREA CODE
PERMIT NO.
MO-
Does the sludge or biosolids disposal comply with federal sludge regulations under 40 CFR 503?
12.9
Yes
No
(Explain)
13. ELECTRONIC DISCHARGE MONITORING REPORT (eDMR) SUBMISSION SYSTEM
Per 40 CFR Part 127 National Pollutant Discharge Elimination System (NPDES) Electronic Reporting Rule, reporting of effluent limits
and monitoring shall be submitted by the permittee via an electronic system to ensure timely, complete, accurate, and nationally
consistent set of data. One of the following must be checked in order for this application to be considered complete. Please
visit
http://dnr.mo.gov/env/wpp/edmr.htm
to access the Facility Participation Package.
- You have completed and submitted with this permit application the required documentation to participate in the eDMR system.
- You have previously submitted the required documentation to participate in the eDMR system and/or you are currently using the
eDMR system.
- You have submitted a written request for a waiver from electronic reporting. See instructions for further information regarding
waivers.
14. CERTIFICATION
I certify that I am familiar with the information contained in the application, that to the best of my knowledge and belief such
information is true, complete and accurate, and if granted this permit, I agree to abide by the Missouri Clean Water Law and all rules,
regulations, orders and decisions, subject to any legitimate appeal available to applicant under the Missouri Clean Water Law.
NAME (TYPE OR PRINT)
OFFICIAL TITLE
TELEPHONE NUMBER WITH AREA CODE
SIGNATURE
DATE SIGNED
MO 780-1512 (09-16)
INSTRUCTIONS FOR COMPLETING FORM B: APPLICATION FOR OPERATING PERMIT FOR FACILITIES
THAT RECEIVE PRIMARILY DOMESTIC WASTE AND HAVE A DESIGN FLOW
LESS THAN OR EQUAL TO 100,000 GALLONS PER DAY
(Facilities over 100,000 gallons per day of domestic waste must use FORM B2)
(Facilities that receive wastes other than domestic contact the department)
1.
Check the appropriate box. Do not check more than one item. Operating permit refers to a permit issued by the
Department of Natural Resources’ Water Protection Program. If an Antidegradation Review has not been conducted, submit
the application located at the following link to the Missouri Department of Natural Resources, Water Protection Program, P.O.
Box 176, Jefferson City, MO 65102:
http://dnr.mo.gov/forms/780-1893-f.pdf
1.1
Fees Information:
DOMESTIC OPERATING PERMIT FEES – PRIVATE
Annual operating permit fees are based on flow.
Annual fee/Design flow
Annual fee/Design flow
Annual fee/Design flow
$150………<5,000 gpd
$1,000……15,000-24,999 gpd
$4,000………100,000-249,999 gpd
$300………5,000-9,999 gpd
$1,500……25,000-29,999 gpd
$5,000………≥250,000 gpd
$600………10,000-14,999 gpd
$3,000……30,000-99,999 gpd
New domestic wastewater treatment facilities must submit the annual fee with the original application.
If the application is for a site-specific permit re-issuance, send no fees. You will be invoiced separately by the
department on the anniversary date of the original permit. Permit fees must be current for the department to reissue the
operating permit. Late fees of two percent per month are charged and added to outstanding annual fees.
PUBLIC SEWER SYSTEM OPERATING PERMIT FEES (city, public sewer district, public water district, or other publicly
owned treatment works). Annual fee is based on number of service connections. Fees listings are found in 10 CSR 20-
6.011 which is available at http://s1.sos.mo.gov/cmsimages/adrules/csr/current/10csr/10c20-6.pdf. New public sewer
system facilities should not submit any fee as the department will invoice the permittee.
OPERATING PERMIT MODIFICATIONS, including transfers, are subject to the following fees:
a.
Publicly Owned Treatment Works (POTWs) - $200 each.
b.
Non-POTWs – $100 each for a minor modification (name changes, address changes, other non-substantive
changes) or a fee equal to 25% of the facility’s annual operating fee for a major modification.
2.
Name of Facility – Include the name by which this facility is locally known. Example: Southwest Sewage Treatment Plant,
Country Club Mobile Home Park, etc. Provide the street address or location of the facility. If the facility lacks a street name or
route number, provide the names of the closest intersection, highway, country road, etc.
2.1
Self-explanatory
2.2
Global Positioning System, or GPS, is a satellite-based navigation system. The department prefers that a GPS receiver is
used at the outfall pipe and the displayed coordinates submitted. If access to a GPS receiver is not available, use a mapping
system to approximate the coordinates; the department’s mapping system is available at www.dnr.mo.gov/internetmapviewer/.
2.3-2.4 Self-explanatory
3.
Owner – Provide the legal name, mailing address, phone number, and email address of the owner.
Prior to submitting a permit to public notice, the Department of Natural Resources shall provide the permit applicant 15 days to
review the draft permit for nonsubstantive drafting errors. In the interest of expediting permit issuance, permit applicants may
waive the opportunity to review draft permits prior to public notice.
3.2-3.4 Self-explanatory.
4.
Continuing Authority – Include the permanent organization that will serve as the continuing authority for the operation,
maintenance and modernization of the facility. The regulatory requirement regarding continuing authority is available at
http://s1.sos.mo.gov/cmsimages/adrules/csr/current/10csr/10c20-6.pdf
or contact the Department of Natural Resources Water
Protection Program (see contact information below).
5.
Operator – Provide the name, certificate number, title, mailing address, phone number, and e-mail address of the operator of
the facility.
6.
Provide the name, title, mailing address, work phone number, and e-mail address 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.
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