"Application for Coverage Under the Water Pollution Control Facility Wpcf-1000 General Permit" - Oregon

Application for Coverage Under the Water Pollution Control Facility Wpcf-1000 General Permit is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

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  • Released on April 27, 2018;
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DEQ USE ONLY
APPLICATION FOR COVERAGE
DEQ USE ONLY
REGIONAL OFFICE
UNDER THE WATER POLLUTION
Received:
Received:
CONTROL FACILITY WPCF-1000
Received:
Application #:
Surcharge:
GENERAL PERMIT
#:
#:
LLID/RM:
#:
DOC Conf.:
Notes:____________________________________
_________________________________________
_________________________________________
Oregon Department of Environmental Quality
A. REFERENCE INFORMATION
1. Legal Name of Applicant:
2. Common Facility Name:
3. Enter Site Location by Latitude and Longitude:
4. Facility Contact
Telephone #:
Deg.
Min.
Sec.
LATITUDE
Fax #:
LONGITUDE
Deg.
Min.
Sec.
Email:
5. Physical Address:
6. Mailing Address:
City, State, Zip:
City, State, Zip:
7. Invoice to:
Telephone #:
Billing Address:
City, State, Zip Code:
B. GENERAL DESCRIPTION OF FACILITY
Briefly describe the facility and primary method of storm water treatment and disposal.
C. REQUIRED INFORMATION
Attach a copy of:
1. A map of the facility location.
2. A site map showing the facility layout and storm water drainage include location of wells, vehicle/equipment wash
areas, and U.I.C.s (drywells, infiltration trenches, etc.).
3. Schedule for development, if this is a new facility being constructed.
4. Schematic diagrams of waste streams, and treatment and disposal facilities.
5. Groundwater information.
6. Evaluation of groundwater and surface water impacts.
D. OTHER PERMITS
List any existing permits for this site.
E. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
I hereby certify that the information contained in this application is true and correct to the best of my knowledge and
belief. In addition, I agree to pay all permit fees required by Oregon Administrative Rules 340-45 and/or 340-71. This
includes an application fee and fee invoiced annually by DEQ to maintain the permit.
(Type or Print)
Title
Name of Legally Authorized Representative
Signature of Legally Authorized Representative
Date
20180427~TLB
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DEQ USE ONLY
APPLICATION FOR COVERAGE
DEQ USE ONLY
REGIONAL OFFICE
UNDER THE WATER POLLUTION
Received:
Received:
CONTROL FACILITY WPCF-1000
Received:
Application #:
Surcharge:
GENERAL PERMIT
#:
#:
LLID/RM:
#:
DOC Conf.:
Notes:____________________________________
_________________________________________
_________________________________________
Oregon Department of Environmental Quality
A. REFERENCE INFORMATION
1. Legal Name of Applicant:
2. Common Facility Name:
3. Enter Site Location by Latitude and Longitude:
4. Facility Contact
Telephone #:
Deg.
Min.
Sec.
LATITUDE
Fax #:
LONGITUDE
Deg.
Min.
Sec.
Email:
5. Physical Address:
6. Mailing Address:
City, State, Zip:
City, State, Zip:
7. Invoice to:
Telephone #:
Billing Address:
City, State, Zip Code:
B. GENERAL DESCRIPTION OF FACILITY
Briefly describe the facility and primary method of storm water treatment and disposal.
C. REQUIRED INFORMATION
Attach a copy of:
1. A map of the facility location.
2. A site map showing the facility layout and storm water drainage include location of wells, vehicle/equipment wash
areas, and U.I.C.s (drywells, infiltration trenches, etc.).
3. Schedule for development, if this is a new facility being constructed.
4. Schematic diagrams of waste streams, and treatment and disposal facilities.
5. Groundwater information.
6. Evaluation of groundwater and surface water impacts.
D. OTHER PERMITS
List any existing permits for this site.
E. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
I hereby certify that the information contained in this application is true and correct to the best of my knowledge and
belief. In addition, I agree to pay all permit fees required by Oregon Administrative Rules 340-45 and/or 340-71. This
includes an application fee and fee invoiced annually by DEQ to maintain the permit.
(Type or Print)
Title
Name of Legally Authorized Representative
Signature of Legally Authorized Representative
Date
20180427~TLB
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APPLICATION INSTRUCTIONS FOR WPCF-1000 PERMIT
Please answer all questions. An incomplete application will not be processed.
If the information requested is not applicable, please indicate as such.
A. REFERENCE INFORMATION:
1. Enter the legal name of the applicant. This must be the legal Oregon corporate name (i.e., Acme
Products, Inc.) or the legal representative of the company if the company operates under an assumed
business name (i.e., John Smith, dba Acme Products). The name must be a legal, active name registered
with the Oregon Department of Commerce, Corporation Division (503) 378-4752, unless otherwise
exempted by the Department of Commerce regulations.
2. Enter the common name of this facility if different than the legal name.
3. Enter the latitude and longitude of the approximate center of the facility or site in degrees/minutes/seconds.
Latitude and longitude can be obtained from United States Geological Survey (USGS) quadrangle or
topographic maps, by calling 1(888) ASK-USGS, or by accessing the
Microsoft website
or the
U.S.
Census
website.
Latitude and longitude for a facility in decimal form must be converted to degrees (º), minutes ('), and seconds (")
for proper entry on the certification form. To convert decimal latitude or longitude degrees/minutes/seconds,
follow the steps in the following example.
Example: Convert decimal latitude 45.1234567 to degrees (º), minutes ('), and seconds (").
The numbers to the left of the decimal point are the degrees: 45º.
a)
To obtain minutes, multiply the first four numbers to the right of the decimal point by 0.006: 1234 x 0.006 =
b)
7.404.
The numbers to the left of the decimal point in the result obtained in (b) are the minutes: 7'.
c)
To obtain seconds, multiply the remaining three numbers to the right of the decimal from the result
d)
obtained in (b) by 0.06: 404 x 0.06 = 24.24. Since the numbers to the right of the decimal point are not
used, the result is 24'.
e) The conversion for 45.1234567 = 45 º 7' 24".
4. Enter the name, telephone and fax number of the facility contact; this would be the person to call in case
there are any questions about this application.
5. Enter the physical location of the facility (not mailing address), including city, state.
6. Enter the mailing address of the facility if different from the physical location.
7. Enter invoicing information for billing purposes if different from legal name, telephone #, and mailing address.
B. GENERAL DESCRIPTION OF FACILITY:
Briefly describe the facility. What goes on here? For other than Storm Water, describe the primary
wastewater treatment and disposal.
C. REQUIRED INFORMATION:
Supply the applicable items for the facility. Insure that a location map and a site layout map are provided for all
sites.
D. OTHER PERMITS:
List the other existing permits for this facility with permit numbers.
C. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE:
The signature of a legally authorized representative must be provided in order to process this application. See
definition.
Definition of Legally Authorized Representative:
Please also provide the information requested in [brackets]
Corporation — president, secretary, treasurer, vice-president, or any person who performs principal business
functions; or a manager of one or more facilities that is authorized in accordance to corporate procedure to sign such
documents
Partnership — General partner [list of general partners, their addresses and telephone numbers]
Sole Proprietorship — Owner(s) [each owner must sign the application]
City, County, State, Federal, or other Public Facility — Principal executive officer or ranking elected official
Limited Liability Company — Member [articles of organization]
Trusts — Acting trustee [list of trustees, their addresses and telephone numbers]
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E.
FEE AND APPLICATION SUBMITTAL:
Please see the cover letter enclosed with this application form or call the appropriate regional office below for fee
Information and to determine where to send this application. Send this form and fee to the regional office.
Please reference the current
fee table
to determine the appropriate fees for your permit. Make your check
payable to the Department of Environmental Quality.
Send this form and fee to the appropriate DEQ regional office:
Make your check payable to the Department of Environmental Quality.
DEQ Northwest Region
DEQ Western Region
DEQ Eastern Region
700 NE Multnomah St, Suite 600
750 Front St. NE, Suite 120
800 SE Emigrant, Suite 330
Portland, OR 97232
Salem, OR 97301-1039
Pendleton, OR 97801
(503)229-5263 or 1-800-452-4011
(503)378-8240 or 1-800-349-7677
(541)276-4063 or 1-800-452-4011
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