Form ECY020-84 "Industrial Stormwater General Permit Application Form (Notice of Intent)" - Washington

What Is Form ECY020-84?

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 May 1, 2015;
  • 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 ECY020-84 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 ECY020-84 "Industrial Stormwater General Permit Application Form (Notice of Intent)" - Washington

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Industrial Stormwater General Permit
Update Permit Information
Application Form (Notice of Intent)
Renewal
Permit No.
.
New Permit Application
All sections are required unless otherwise noted. This form is not password protected. Use F11 to navigate fill-
in fields.
I. Permittee Information
(All permit and billing correspondence will be mailed here)
Permittee’s Name
Company Name
Title
Universal Business Identifier (UBI) Number
Phone No.
Fax No.
Street Address or P.O. Box
E-mail
City
State
Zip + 4
II. Facility Information
Name of Facility
Date facility began operation or will begin operation
Facility Contact Name
Phone No.
Facility Contact Email Address
Fax No.
Facility Street Address (or Location Description)
Record site location at front door or site entrance
Latitude
Longitude
City
State
Zip + 4
County
Size of Site in Acres
A. List all Standard Industrial Classification (SIC) codes below, with the primary SIC code in box a; as well
as all North American Industry Classification System (NAICS) codes, with the primary NAICS code in
box a. Your lists must include all industrial activities performed at your facility. (See Table 1 in the
permit for a list of activities that require permit coverage.) A crosswalk between SIC codes and NAICS
code is available online at http://www.census.gov/epcd/www/naicstab.htm.
SIC
a
b
c
d
Codes
NAICS
a
b
c
d
Codes
B. Type or Nature of Industrial Activities:
.
C. Is this facility a Hazardous Waste Treatment, Storage, and Disposal (TSD) facility regulated under
Chapter 173-303 WAC?
Yes
No
D. For Airport Facilities:
1. Is the facility located at an airport where a single facility, or a combination of facilities, use
more than 100,000 gallons of glycol-based deicing chemicals and/or 100 tons or more of urea on
an average annual basis?
Yes
No
If yes, identify the sampling points that collect runoff from deicing activities:
.
ECY 020-84 (Rev. 05/15)
Page 1
Industrial Stormwater General Permit
Update Permit Information
Application Form (Notice of Intent)
Renewal
Permit No.
.
New Permit Application
All sections are required unless otherwise noted. This form is not password protected. Use F11 to navigate fill-
in fields.
I. Permittee Information
(All permit and billing correspondence will be mailed here)
Permittee’s Name
Company Name
Title
Universal Business Identifier (UBI) Number
Phone No.
Fax No.
Street Address or P.O. Box
E-mail
City
State
Zip + 4
II. Facility Information
Name of Facility
Date facility began operation or will begin operation
Facility Contact Name
Phone No.
Facility Contact Email Address
Fax No.
Facility Street Address (or Location Description)
Record site location at front door or site entrance
Latitude
Longitude
City
State
Zip + 4
County
Size of Site in Acres
A. List all Standard Industrial Classification (SIC) codes below, with the primary SIC code in box a; as well
as all North American Industry Classification System (NAICS) codes, with the primary NAICS code in
box a. Your lists must include all industrial activities performed at your facility. (See Table 1 in the
permit for a list of activities that require permit coverage.) A crosswalk between SIC codes and NAICS
code is available online at http://www.census.gov/epcd/www/naicstab.htm.
SIC
a
b
c
d
Codes
NAICS
a
b
c
d
Codes
B. Type or Nature of Industrial Activities:
.
C. Is this facility a Hazardous Waste Treatment, Storage, and Disposal (TSD) facility regulated under
Chapter 173-303 WAC?
Yes
No
D. For Airport Facilities:
1. Is the facility located at an airport where a single facility, or a combination of facilities, use
more than 100,000 gallons of glycol-based deicing chemicals and/or 100 tons or more of urea on
an average annual basis?
Yes
No
If yes, identify the sampling points that collect runoff from deicing activities:
.
ECY 020-84 (Rev. 05/15)
Page 1
2. How many annual jet departures take place at your airport?
10,000 or more (contact your Permit Administrator)
1,000 or more, less than 10,000 (go to 2a)
Less than 1000 (go to Section III)
2a. On airports with 1,000 or more annual jet departures; does the facility discharge
wastewater associated with airfield pavement deicing with stormwater?
Yes (go to 2b)
No (go to Section III).
2b. If yes, do you use urea containing deicers?
Yes
No
III. Other Permits Check all that apply.
NPDES Permit (Individual or General) Permit No.
State Waste Discharge Permit (Individual or General) Permit
No.
IV. Site Information
A. Indicate where your site’s stormwater could enter waters of the state, directly and/or indirectly:
Water will discharge directly or indirectly (through a storm drain system or roadside ditch) into one or
more surface waterbodies (wetlands, creeks, lakes, and all other surface waters and water courses).
Water will discharge to ground with 100% infiltration, with no potential to reach surface waters under
any conditions. (If checked, skip to section V.)
B. Discharge Point(s) Latitude and Longitude: Provide latitude and longitude in degrees (°), minutes (‘),
and seconds (“) for each of your facility’s discharge point(s). List all discharge points. Use an extra
sheet of paper if necessary. For sites with 100% infiltration, identify provide the location where the
water collects for infiltration or the center of the facility if no stormwater collects onsite.
For the discharge identifier, list the name, number, or letter used on your site map to identify the
point(s) of discharge. The identifier can be a maximum of three characters long and must be unique
for each discharge point.
If you identify more than one discharge point, mark the discharge point(s) you will sample to comply
with the permit sampling requirements by checking the Sample Point box.
NOTE: Ecology uses the unique identifier given to identify the sampling point in WQWebDMR.
Discharge
Latitude
Longitude
Sample Point
Location
identifier. These
degrees, minutes,
degrees, minutes,
description
cannot be symbols.
seconds
seconds
(maximum of three
characters e.g.,
01A)
N
W
N
W
N
W
N
W
C. Receiving Water Latitude / Longitude: Provide latitude and longitude in degrees (°), minutes (‘), and
seconds (“) of you facility’s discharge where it enters the lake, river, stream, or pond. List all receiving
waters for the site. Use an extra sheet of paper if necessary
Receiving Waterbody
Latitude
Longitude
degrees, minutes, seconds
degrees, minutes, seconds
N
W
N
W
N
W
ECY 020-84 (Rev. 05/15)
Page 2
N
W
N
W
You must submit monthly discharge monitoring reports using Ecology’s WQWebDMR system. To
sign up for WQWebDMR, or to register a new site, go to www.ecy.wa.gov/stormwater, and click on the
“Industrial Permit” link. You will find information on WebDMR under the “WQWebDMR and PARIS” link on
the right-hand side.
To have the ability to use the system immediately, you must submit the Electronic Signature Agreement
with your application. If you have questions on this process, contact Ecology’s WebDMR staff at
WAWebDMR-Stormwater@ecy.wa.gov
or 360-407-7097.
If you are unable to submit your DMRs electronically, you may contact Ecology to request a waiver. Ecology will
generally only grant waiver requests to those permittees without internet access. Only a permittee or representative,
designated in writing, may request access to or a waiver from WebDMR.
V. State Environmental Policy Act (SEPA)
Applies only to facilities that began operations after January 2, 2015.
Has a SEPA review been completed?
Yes
No
Exempt
Type of SEPA determination:
Determination of Non-Significance (DNS)
Final Environmental
Impact Statement (EIS)
Mitigated DNS (MDNS)
Agency issuing DNS, MDNS, Final EIS, or Exemption:
Date:
VI. Public Notice
New Facilities beginning operations after January 2, 2015 and new dischargers (see instructions) must
publish a public notice at least once a week for two consecutive weeks with seven days in between
publications, in a single newspaper of general circulation in the county in which the facility is located.
Ecology cannot grant permit coverage earlier than the end of the 30-day public comment period, which
begins on the date of the second public notice.
Submit (or fax: 360-407-6426) the application to Ecology on or before the date of the first public notice. If
you fax the application to Ecology, you must follow up with hard copy by mail within 10 days.
Date of the first public notice:
Date of second public notice:
(Begins 30-day public comment period)
Example: Date of the first public notice: 01/02/2015
Date of second public notice: 01/08/2015
Name of the newspaper that will publish the public notices:
Complete this template using site-specific information. The bold language is required by WAC 173-226-130 and must
be included in its entirety. (Either use the fill-in template below or attach on a separate sheet of paper, if necessary.)
ECY 020-84 (Rev. 05/15)
Page 3
Enter name of applicant, Enter name and address of facility is seeking coverage under the Washington
State Department of Ecology’s Industrial Stormwater NPDES and State Waste Discharge General
Permit.
The industrial site, known as Site name
is located at Enter street address
in Enter name
of nearest city
. Operations will start up on/started on (select one) Enter date
. Industrial
activities include Briefly describe the industrial activity
. Stormwater from the site
discharges to List unnamed and named receiving waters
.
Any persons desiring to present their views to the Washington State Department of Ecology
regarding this application, or interested in Ecology’s action on this application, may notify Ecology
in writing no later than 30 days of the last date of publication of this notice.
Ecology will review all public comments regarding Tier II antidegradation and consider whether
discharges from this facility are expected to cause a measurable change in the quality of the
receiving water and, if so, whether such change is necessary and in the overriding public interest.
Comments can be sent to:
Washington Dept of Ecology
Water Quality Program – Industrial Stormwater
PO Box 47696
Olympia, WA 98504-7696
ECY 020-84 (Rev. 05/15)
Page 4
VII. Certification of Permittee*
“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 fine and imprisonment for knowing violations.”
Printed Name
Company
Title
Signature
Date
*Federal regulations require this application is signed by one of the following:
A. In the case of corporations, by a principal executive officer of at least the level of vice president.
B. In the case of a partnership, by a general partner of a partnership.
C. In the case of sole proprietorship, by the proprietor.
D. In the case of a municipality, state, federal, or other public facility: by either a principal executive officer
or ranking elected official.
Return this signed original document to the below address. Make sure you retain a copy for your records.
Washington Department of Ecology
Water Quality Program – Industrial Stormwater
PO Box 47696
Olympia, WA 98504-7696
If you have any questions, please call:
Shawn Hopkins 360-407-6442 or
shawn.hopkins@ecy.wa.gov
for Adams, Asotin, Columbia,
Ferry, Franklin, Garfield, Grant, Lincoln, Pend Oreille, Skagit, Snohomish, Spokane, Stevens, Walla
Walla, Whatcom, and Whitman counties.
Clay Keown 360-407-6048 or
clay.keown@ecy.wa.gov
for Island, King (except Seattle), and San
Juan counties.
Josh Klimek 360-407-7451 or
josh.klimek@ecy.wa.gov
for city of Seattle and Kitsap, Pierce, and
Thurston counties
Joyce Smith 360-407-6858 or
joyce.smith@ecy.wa.gov
for Benton, Chelan, Clallam, Clark,
Cowlitz, Douglas, Grays Harbor, Jefferson, Kittitas, Klickitat, Lewis, Mason Okanogan, Pacific,
Skamania, Wahkiakum, and Yakima counties.
If you need this document in a version for the visually impaired call the Water Quality Program at 360-407-
6401. Persons with hearing loss, call 711 for Washington Relay Service. Persons with a speech disability,
call 877-833-6341.
ECY 020-84 (Rev. 05/15)
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