Form ECY040-180 "Categorical State Waste Discharge Permit Application for Industrial Discharges to Land - Hanford Specific" - Washington

What Is Form ECY040-180?

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

Form Details:

  • Released on September 1, 2001;
  • The latest edition provided by the Washington State Department of Ecology;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ECY040-180 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

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Download Form ECY040-180 "Categorical State Waste Discharge Permit Application for Industrial Discharges to Land - Hanford Specific" - Washington

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Category: _______________
CATEGORICAL STATE WASTE
DISCHARGE PERMIT APPLICATION
FOR INDUSTRIAL DISCHARGES TO
LAND – HANFORD SPECIFIC
FOR STATE USE ONLY
Date Application
Date Fee
Application/
Received
Paid
Permit Number
Date Application
Facility
Accepted
Number
Temporary Permit
Temporary Permit
Effective Date
Expiration Date
This application is for a waste discharge permit as required in accordance with provisions of Chapter 90.48 RCW and Chapter 173-
216 WAC. Additional information may be required. Information previously submitted and applicable to this application should be
referenced in the appropriate section.
GENERAL INFORMATION
1. Company Name: ______________________________________________________________________
2. Unified Business Identification Number (UBI#): _____________________________________________
3. Mailing Address: ______________________________________________________________________
Street
______________________________________________________________________
City/State
Zip
4. Facility Location: ______________________________________________________________________
Street or Other Description
______________________________________________________________________
City/State
5. Person to contact who is familiar with the information contained in this application:
Name
Title
Telephone
6. Check One: ____
Permit Renewal
___ Existing Unpermitted Discharge
____ Proposed Discharge
Anticipated date of discharge: _________
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance
with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, including the possibility of a fine and/or imprisonment for knowing violations.
_______________________________________
_____________________
________________________
Signature*
Date
Title
________________________
Printed Name
*Applications must be signed as follows: A municipal, state, federal, or other public facility, by either a principal executive officer or ranking elected official.
If you require this document in an alternate format, please contact the Nuclear Waste Program at 509-735-7581 or TTY 711 or 1-800-833-6388.
ECY 040-180 (9/01)
1
Category: _______________
CATEGORICAL STATE WASTE
DISCHARGE PERMIT APPLICATION
FOR INDUSTRIAL DISCHARGES TO
LAND – HANFORD SPECIFIC
FOR STATE USE ONLY
Date Application
Date Fee
Application/
Received
Paid
Permit Number
Date Application
Facility
Accepted
Number
Temporary Permit
Temporary Permit
Effective Date
Expiration Date
This application is for a waste discharge permit as required in accordance with provisions of Chapter 90.48 RCW and Chapter 173-
216 WAC. Additional information may be required. Information previously submitted and applicable to this application should be
referenced in the appropriate section.
GENERAL INFORMATION
1. Company Name: ______________________________________________________________________
2. Unified Business Identification Number (UBI#): _____________________________________________
3. Mailing Address: ______________________________________________________________________
Street
______________________________________________________________________
City/State
Zip
4. Facility Location: ______________________________________________________________________
Street or Other Description
______________________________________________________________________
City/State
5. Person to contact who is familiar with the information contained in this application:
Name
Title
Telephone
6. Check One: ____
Permit Renewal
___ Existing Unpermitted Discharge
____ Proposed Discharge
Anticipated date of discharge: _________
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance
with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, including the possibility of a fine and/or imprisonment for knowing violations.
_______________________________________
_____________________
________________________
Signature*
Date
Title
________________________
Printed Name
*Applications must be signed as follows: A municipal, state, federal, or other public facility, by either a principal executive officer or ranking elected official.
If you require this document in an alternate format, please contact the Nuclear Waste Program at 509-735-7581 or TTY 711 or 1-800-833-6388.
ECY 040-180 (9/01)
1
Category: __________
IDENTIFY WASTE STREAMS
1.
On an attached sheet, briefly describe the types of discharges included in this categorical permit
application.
2.
List each stream included in this categorical permit application and assign each waste stream an
identification number.
ID
Process
Waste Stream
B/C/S
Estimated
No.
Name/Location
Process
Quantity
*B = Batch, C = Continuous, S = Seasonal
SOURCE/WASTEWATER DESCRIPTION
3.
On an attached sheet, briefly describe all source water used to generate waste streams. Also describe
concentrations measured, analytical methods, and detection limits. Explain instances where constituent
levels exceed ground water criteria.
4.
Provide additional process knowledge that could effect constituent concentrations.
ECY 040-180 (9/01)
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