Form 0210-PM-PIO0001 "General Information Form - Authorization Application" - Pennsylvania

What Is Form 0210-PM-PIO0001?

This is a legal form that was released by the Pennsylvania Department of Environmental Protection - a government authority operating within Pennsylvania. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Pennsylvania Department of Environmental Protection;
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Download Form 0210-PM-PIO0001 "General Information Form - Authorization Application" - Pennsylvania

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0210-PM-PIO0001
4/2018
Form
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
GENERAL INFORMATION FORM – AUTHORIZATION APPLICATION
Before completing this General Information Form (GIF), read the step-by-step instructions provided in this application package.
This version of the General Information Form (GIF) must be completed and returned with any program-specific application being
submitted to the Department.
Related ID#s (If Known)
DEP USE ONLY
Date Received & General Notes
Client ID#
APS ID#
Site ID#
Auth ID#
Facility ID#
CLIENT INFORMATION
DEP Client ID#
Client Type / Code
Organization Name or Registered Fictitious Name
Employer ID# (EIN)
Dun & Bradstreet ID#
Individual Last Name
First Name
MI
Suffix
SSN
Additional Individual Last Name
First Name
MI
Suffix
SSN
Mailing Address Line 1
Mailing Address Line 2
Address Last Line – City
State
ZIP+4
Country
Client Contact Last Name
First Name
MI
Suffix
Client Contact Title
Phone
Ext
Email Address
FAX
SITE INFORMATION
DEP Site ID#
Site Name
EPA ID#
Estimated Number of Employees to be Present at Site
Description of Site
County Name
Municipality
City
Boro
Twp
State
County Name
Municipality
City
Boro
Twp
State
Site Location Line 1
Site Location Line 2
Site Location Last Line – City
State
ZIP+4
Detailed Written Directions to Site
Site Contact Last Name
First Name
MI
Suffix
Site Contact Title
Site Contact Firm
Mailing Address Line 1
Mailing Address Line 2
Mailing Address Last Line – City
State
ZIP+4
Page 1 of 7
0210-PM-PIO0001
4/2018
Form
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
GENERAL INFORMATION FORM – AUTHORIZATION APPLICATION
Before completing this General Information Form (GIF), read the step-by-step instructions provided in this application package.
This version of the General Information Form (GIF) must be completed and returned with any program-specific application being
submitted to the Department.
Related ID#s (If Known)
DEP USE ONLY
Date Received & General Notes
Client ID#
APS ID#
Site ID#
Auth ID#
Facility ID#
CLIENT INFORMATION
DEP Client ID#
Client Type / Code
Organization Name or Registered Fictitious Name
Employer ID# (EIN)
Dun & Bradstreet ID#
Individual Last Name
First Name
MI
Suffix
SSN
Additional Individual Last Name
First Name
MI
Suffix
SSN
Mailing Address Line 1
Mailing Address Line 2
Address Last Line – City
State
ZIP+4
Country
Client Contact Last Name
First Name
MI
Suffix
Client Contact Title
Phone
Ext
Email Address
FAX
SITE INFORMATION
DEP Site ID#
Site Name
EPA ID#
Estimated Number of Employees to be Present at Site
Description of Site
County Name
Municipality
City
Boro
Twp
State
County Name
Municipality
City
Boro
Twp
State
Site Location Line 1
Site Location Line 2
Site Location Last Line – City
State
ZIP+4
Detailed Written Directions to Site
Site Contact Last Name
First Name
MI
Suffix
Site Contact Title
Site Contact Firm
Mailing Address Line 1
Mailing Address Line 2
Mailing Address Last Line – City
State
ZIP+4
Page 1 of 7
0210-PM-PIO0001
4/2018
Form
Phone
Ext
FAX
Email Address
(Two- & Three-Digit Codes – List All That Apply)
NAICS Codes
6-Digit Code (Optional)
Client to Site Relationship
FACILITY INFORMATION
Modification of Existing Facility
Yes
No
1.
Will this project modify an existing facility, system, or activity?
2.
Will this project involve an addition to an existing facility, system, or activity?
If “Yes”, check all relevant facility types and provide DEP facility identification numbers below.
Facility Type
DEP Fac ID#
Facility Type
DEP Fac ID#
Air Emission Plant
Industrial Minerals Mining Operation
Beneficial Use (water)
Laboratory Location
Blasting Operation
Land Recycling Cleanup Location
Captive Hazardous Waste Operation
Mine DrainageTrmt/LandRecyProjLocation
Coal Ash Beneficial Use Operation
Municipal Waste Operation
Coal Mining Operation
Oil & Gas Encroachment Location
Coal Pillar Location
Oil & Gas Location
Commercial Hazardous Waste Operation
Oil & Gas Water Poll Control Facility
Dam Location
Oil & Gas Wastewater Storage Impoundment
Deep Mine Safety Operation -Anthracite
Public Water Supply System
Deep Mine Safety Operation -Bituminous
Radiation Facility
Deep Mine Safety Operation -Ind Minerals
Residual Waste Operation
Encroachment Location (water, wetland)
Storage Tank Location
Erosion & Sediment Control Facility
Water Pollution Control Facility
Explosive Storage Location
Water Resource
Other:
Latitude/Longitude
Latitude
Longitude
Point of Origin
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
Horizontal Accuracy Measure
Feet
--or--
Meters
Horizontal Reference Datum Code
North American Datum of 1927
North American Datum of 1983
World Geodetic System of 1984
Horizontal Collection Method Code
Reference Point Code
Altitude
Feet
--or--
Meters
Altitude Datum Name
The National Geodetic Vertical Datum of 1929
The North American Vertical Datum of 1988 (NAVD88)
Altitude (Vertical) Location Datum Collection Method Code
Geometric Type Code
Data Collection Date
Source Map Scale Number
Inch(es)
=
Feet
=
--or--
Centimeter(s)
Meters
PROJECT INFORMATION
Project Name
Project Description
Project Consultant Last Name
First Name
MI
Suffix
Project Consultant Title
Consulting Firm
Mailing Address Line 1
Mailing Address Line 2
Page 2 of 7
0210-PM-PIO0001
4/2018
Form
Address Last Line – City
State
ZIP+4
Phone
Ext
FAX
Email Address
Time Schedules
Project Milestone (Optional)
1.
Have you informed the surrounding community and addressed any
Yes
No
concerns prior to submitting the application to the Department?
2.
Is your project funded by state or federal grants?
Yes
No
If “Yes”, specify what aspect of the project is related to the grant and provide the grant source, contact person
Note:
and grant expiration date.
Aspect of Project Related to Grant
Grant Source:
Grant Contact Person:
Grant Expiration Date:
3.
Is this application for an authorization on Appendix A of the Land Use
Yes
No
Policy?
(For referenced list, see Appendix A of the Land Use Policy
attached to GIF instructions)
If “No” to Question 3, the application is not subject to the Land Use Policy.
Note:
If “Yes” to Question 3, the application is subject to this policy and the Applicant should answer the additional
questions in the Land Use Information section.
LAND USE INFORMATION
Note: Applicants are encouraged to submit copies of local land use approvals or other evidence of compliance with
local comprehensive plans and zoning ordinances.
1.
Is there an adopted county or multi-county comprehensive plan?
Yes
No
Yes
No
2.
Is there an adopted municipal or multi-municipal comprehensive plan?
Yes
No
3.
Is there an adopted county-wide zoning ordinance, municipal zoning
ordinance or joint municipal zoning ordinance?
If the Applicant answers “No” to either Questions 1, 2 or 3, the provisions of the PA MPC are not applicable and
Note:
the Applicant does not need to respond to questions 4 and 5 below.
If the Applicant answers “Yes” to questions 1, 2 and 3, the Applicant should respond to questions 4 and 5 below.
Yes
No
4.
Does the proposed project meet the provisions of the zoning ordinance or
does the proposed project have zoning approval?
If zoning approval has been
received, attach documentation.
5.
Have you attached Municipal and County Land Use Letters for the project?
Yes
No
Page 3 of 7
0210-PM-PIO0001
4/2018
Form
COORDINATION INFORMATION
Note: The PA Historical and Museum Commission must be notified of proposed projects in accordance with DEP
Technical Guidance Document 012-0700-001 and the accompanying Cultural Resource Notice Form.
If the activity will be a mining project (i.e., mining of coal or industrial minerals, coal refuse disposal and/or the
operation of a coal or industrial minerals preparation/processing facility), respond to questions 1.0 through 2.5
below.
If the activity will not be a mining project, skip questions 1.0 through 2.5 and begin with question 3.0.
Is this a coal mining project? If “Yes”, respond to 1.1-1.6. If “No”, skip to
Yes
No
1.0
Question 2.0.
1.1
Will this coal mining project involve coal preparation/ processing
Yes
No
activities in which the total amount of coal prepared/processed will be
equal to or greater than 200 tons/day?
Yes
No
1.2
Will this coal mining project involve coal preparation/ processing
activities in which the total amount of coal prepared/processed will be
greater than 50,000 tons/year?
1.3
Will this coal mining project involve coal preparation/ processing
Yes
No
activities in which thermal coal dryers or pneumatic coal cleaners will be
used?
1.4
For this coal mining project, will sewage treatment facilities be
Yes
No
constructed and treated waste water discharged to surface waters?
1.5
Will this coal mining project involve the construction of a permanent
Yes
No
impoundment meeting one or more of the following criteria:
(1) a
contributory drainage area exceeding 100 acres; (2) a depth of water
measured by the upstream toe of the dam at maximum storage elevation
exceeding 15 feet; (3) an impounding capacity at maximum storage
elevation exceeding 50 acre-feet?
Yes
No
1.6
Will this coal mining project involve underground coal mining to be
conducted within 500 feet of an oil or gas well?
Is this a non-coal (industrial minerals) mining project? If “Yes”, respond to
2.0
Yes
No
2.1-2.6. If “No”, skip to Question 3.0.
2.1
Will this non-coal (industrial minerals) mining project involve the
Yes
No
crushing and screening of non-coal minerals other than sand and
gravel?
2.2
Will this non-coal (industrial minerals) mining project involve the
Yes
No
crushing and/or screening of sand and gravel with the exception of wet
sand and gravel operations (screening only) and dry sand and gravel
operations with a capacity of less than 150 tons/hour of unconsolidated
materials?
2.3
Will this non-coal (industrial minerals) mining project involve the
Yes
No
construction, operation and/or modification of a portable non-metallic
(i.e., non-coal) minerals processing plant under the authority of the
General Permit for Portable Non-metallic Mineral Processing Plants (i.e.,
BAQ-PGPA/GP-3)?
2.4
For this non-coal (industrial minerals) mining project, will sewage
Yes
No
treatment facilities be constructed and treated waste water discharged to
surface waters?
Yes
No
2.5
Will this non-coal (industrial minerals) mining project involve the
construction of a permanent impoundment meeting one or more of the
following criteria: (1) a contributory drainage area exceeding 100 acres;
(2) a depth of water measured by the upstream toe of the dam at
maximum storage elevation exceeding 15 feet; (3) an impounding
capacity at maximum storage elevation exceeding 50 acre-feet?
Page 4 of 7
0210-PM-PIO0001
4/2018
Form
Yes
No
3.0
Will your project, activity, or authorization have anything to do with a
well related to oil or gas production, have construction within 200 feet of,
affect an oil or gas well, involve the waste from such a well, or string
power lines above an oil or gas well? If “Yes”, respond to 3.1-3.3. If “No”,
skip to Question 4.0.
Yes
No
3.1
Does the oil- or gas-related project involve any of the following:
placement of fill, excavation within or placement of a structure, located
in, along, across or projecting into a watercourse, floodway or body of
water (including wetlands)?
3.2
Will the oil- or gas-related project involve discharge of industrial
Yes
No
wastewater or stormwater to a dry swale, surface water, ground water or
If “Yes”,
an existing sanitary sewer system or storm water system?
discuss in Project Description.
3.3
Will the oil- or gas-related project involve the construction and operation
Yes
No
of industrial waste treatment facilities?
Yes
No
4.0
Will the project involve a construction activity that results in earth
disturbance? If “Yes”, specify the total disturbed acreage.
4.0.1
Total Disturbed Acreage
5.0
Does the project involve any of the following?
Yes
No
If “Yes”, respond to 5.1-5.3. If “No”, skip to Question 6.0.
Water Obstruction and Encroachment Projects – Does the project
Yes
No
5.1
involve any of the following:
placement of fill, excavation within or
placement of a structure, located in, along, across or projecting into a
watercourse, floodway or body of water?
Wetland Impacts – Does the project involve any of the following:
Yes
No
5.2
placement of fill, excavation within or placement of a structure, located
in, along, across or projecting into a wetland?
5.3
Floodplain Projects by the commonwealth, a Political Subdivision of the
Yes
No
commonwealth or a Public Utility – Does the project involve any of the
following:
placement of fill, excavation within or placement of a
structure, located in, along, across or projecting into a floodplain?
Yes
No
6.0
Will the project involve discharge of stormwater or wastewater from an
industrial activity to a dry swale, surface water, ground water or an
existing sanitary sewer system or separate storm water system?
Yes
No
7.0
Will the project involve the construction and operation of industrial
waste treatment facilities?
Yes
No
8.0
Will the project involve construction of sewage treatment facilities,
sanitary sewers, or sewage pumping stations? If “Yes”, indicate estimated
proposed flow (gal/day). Also, discuss the sanitary sewer pipe sizes and the
number of pumping stations/treatment facilities/name of downstream sewage
facilities in the Project Description, where applicable.
8.0.1
Estimated Proposed Flow (gal/day)
9.0
Will the project involve the subdivision of land, or the generation of 800
Yes
No
gpd or more of sewage on an existing parcel of land or the generation of
an additional 400 gpd of sewage on an already-developed parcel, or the
generation of 800 gpd or more of industrial wastewater that would be
discharged to an existing sanitary sewer system?
Yes
No
9.0.1
Was Act 537 sewage facilities planning submitted and
approved by DEP? If “Yes” attach the approval letter. Approval
required prior to 105/NPDES approval.
10.0
Is this project for the beneficial use of biosolids for land application
Yes
No
within Pennsylvania? If “Yes” indicate how much (i.e. gallons or dry tons per
year).
10.0.1
Gallons Per Year (residential septage)
10.0.2
Dry Tons Per Year (biosolids)
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