Form DEEP-WPED-APP-001 "Wastewater Discharge Permit Application Checklist" - Connecticut

What Is Form DEEP-WPED-APP-001?

This is a legal form that was released by the Connecticut Department of Energy and Environmental Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
  • Easy to use and ready to print;
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  • Fill out the form in our online filing application.

Download a printable version of Form DEEP-WPED-APP-001 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Energy and Environmental Protection.

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Download Form DEEP-WPED-APP-001 "Wastewater Discharge Permit Application Checklist" - Connecticut

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DEEP USE ONLY
Wastewater Discharge Permit
Application No.
Application Checklist
Permit No.
This Application Checklist (Checklist) has been created to provide guidance to the applicant in the preparation
of a Permit Application for Wastewater Discharges from Manufacturing, Commercial and Other Activities (DEEP-
WPED-APP-100). The Checklist provides information needed to evaluate - by both the applicant and the
Department of Energy and Environmental protection (DEEP) - the completeness of a submitted Water Discharge
Permit Application, as well as to serve as the basis for discussion at a Pre-Application Meeting between the
applicant and DEEP. In an effort to improve our Water Discharge Permitting Process, DEEP has initiated a revised
application process to ensure a more timely review and decision making of submitted applications.
Action required by the Applicant:
Please complete this form in accordance with the instructions below and email it to the assigned DEEP Water
Permitting Engineer when you submit your completed permit application 180 days prior to permit expiration to
DEEP.
You may complete this checklist in preparation of the Pre-Application meeting. DEEP acknowledges that not
all information requested will be available at the Pre-Application meeting time period.
Part I: Application Type and Description
Application Type:
New
Renewal
Modification
Type of Discharge Source:
Type of Receiving Water:
Surface Water
POTW:
Ground Water
Permit Number(s):
Expiration Date(s):
Part II: Fee Information
Initial Filing Fee Paid:
Yes
No
Date:
Amount Paid:
Part III: Applicant Information
*If an applicant is a corporation, limited liability company, limited partnership, limited liability partnership, or a
statutory trust, it must be registered with the Secretary of State. If applicable, the applicant’s name shall be
stated exactly as it is registered with the Secretary of State. Please note, for those entities registered with the
Secretary of State, the registered name will be the name used by DEEP. This information can be accessed at
the Secretary of State's database (CONCORD). (www.concord-sots.ct.gov/CONCORD/index.jsp)
If an applicant is an individual, provide the legal name (include suffix) in the following format: First Name;
Middle Initial; Last Name; Suffix (Jr, Sr., II, III, etc.).
DEEP-WPED-APP-001
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Rev. 10/01/13
DEEP USE ONLY
Wastewater Discharge Permit
Application No.
Application Checklist
Permit No.
This Application Checklist (Checklist) has been created to provide guidance to the applicant in the preparation
of a Permit Application for Wastewater Discharges from Manufacturing, Commercial and Other Activities (DEEP-
WPED-APP-100). The Checklist provides information needed to evaluate - by both the applicant and the
Department of Energy and Environmental protection (DEEP) - the completeness of a submitted Water Discharge
Permit Application, as well as to serve as the basis for discussion at a Pre-Application Meeting between the
applicant and DEEP. In an effort to improve our Water Discharge Permitting Process, DEEP has initiated a revised
application process to ensure a more timely review and decision making of submitted applications.
Action required by the Applicant:
Please complete this form in accordance with the instructions below and email it to the assigned DEEP Water
Permitting Engineer when you submit your completed permit application 180 days prior to permit expiration to
DEEP.
You may complete this checklist in preparation of the Pre-Application meeting. DEEP acknowledges that not
all information requested will be available at the Pre-Application meeting time period.
Part I: Application Type and Description
Application Type:
New
Renewal
Modification
Type of Discharge Source:
Type of Receiving Water:
Surface Water
POTW:
Ground Water
Permit Number(s):
Expiration Date(s):
Part II: Fee Information
Initial Filing Fee Paid:
Yes
No
Date:
Amount Paid:
Part III: Applicant Information
*If an applicant is a corporation, limited liability company, limited partnership, limited liability partnership, or a
statutory trust, it must be registered with the Secretary of State. If applicable, the applicant’s name shall be
stated exactly as it is registered with the Secretary of State. Please note, for those entities registered with the
Secretary of State, the registered name will be the name used by DEEP. This information can be accessed at
the Secretary of State's database (CONCORD). (www.concord-sots.ct.gov/CONCORD/index.jsp)
If an applicant is an individual, provide the legal name (include suffix) in the following format: First Name;
Middle Initial; Last Name; Suffix (Jr, Sr., II, III, etc.).
DEEP-WPED-APP-001
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Rev. 10/01/13
Part III: Applicant Information (continued)
1. Fill in the name, address and phone number of the applicant (s) as indicated on the application. If
the application is incomplete, a notice of insufficiency will be issued to provide missing
information.
Applicant:
Mailing Address:
City/Town:
State:
Zip Code:
Phone:
ext.
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic address,
concerning the subject application. Please remember to check your security settings to be sure you can receive e-mails from “ct.gov”
addresses. Also, please notify DEEP if your e-mail address changes.
1a. Applicant Type:
Company
Government (specify):
Other (specify):
1b. Applicant's interest in property at which the proposed activity is to be located:
site owner
option holder
lessee
easement holder
operator
other (specify):
Are there any co-applicants?
Yes
No
Not Applicable
Label and attach additional sheet(s) with the information requested in item 1,for each co-applicant.
2. Billing contact, if different than the applicant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
3. Primary contact for departmental correspondence and inquiries, if different than the applicant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic address,
concerning the subject application. Please remember to check your security settings to be sure you can receive e-mails from “ct.gov”
addresses. Also, please notify DEEP if your e-mail address changes.
DEEP-WPED-APP-001
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Part III: Applicant Information (continued)
4. Attorney or other representative, if applicable:
Firm Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Attorney:
E-mail:
5. Facility Operator, if different than the applicant:
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
6. Facility Owner, if different than the applicant:
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
7. Property Owner, if different than the applicant:
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
8. List any engineer(s) or other consultant(s) employed or retained to assist in preparing the
application or in designing or constructing the facility.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
Service Provided:
Check here if additional sheets are necessary. Label and attach the sheets to this page.
DEEP-WPED-APP-001
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Part IV: Site and Resource Information
1. SITE NAME AND LOCATION
Name of Site:
Street Address or Location Description:
City/Town:
State:
Zip Code:
2. INDIAN LANDS: Is or will the site be located on federally recognized Indian lands?
Yes
No
3. COASTAL BOUNDARY: Is this an application for a new permit or a modification of an existing permit
where the physical footprint of the subject activity is modified?
Yes
No
If yes, and if the activity which is the subject of this application is located within the coastal boundary as
delineated on DEEP approved coastal boundary maps, you must complete and submit a
Coastal
Consistency Review Form
(DEEP-APP-004) with your application as Attachment E.
Information on the coastal boundary is available at
www.cteco.uconn.edu/map_catalog.asp
(Select the town and then select coastal boundary. If the town is not within the coastal boundary you
or the local town hall or on the “Coastal
map.)
will not be able to select the coastal boundary
Boundary Map” available at DEEP Maps and Publications (860-424-3555).
4. ENDANGERED OR THREATENED SPECIES: Is this an application for a new permit or a modification of
an existing permit where the physical footprint of the subject activity is modified?
Yes
No
If yes, and if the project site is located within an area identified as a habitat for endangered, threatened or
special concern species according to the most current "State and Federal Listed Species and Natural
Communities Map", (Date of Map used to determine:
), complete and submit a
Request for NDDB
State Listed Species Review Form
(DEEP-APP-007) to the address specified on the form. Please note
NDDB review generally takes 4 to 6 weeks and may require additional documentation from the
applicant.
The CT NDDB response must be submitted with this completed application as Attachment F.
For more information visit the DEEP website at
www.ct.gov/deep/nddbrequest
or call the NDDB at 860-
424-3011.
5. AQUIFER PROTECTION AREAS: Is the site located within a mapped Level A or Level B
Aquifer
Protection
Area, as defined in CGS section 22a-354a through 22a-354bb?
Yes
No
If yes, check one:
Level A or
Level B
If Level A, are any of the
regulated
activities, as defined in RCSA section 22a-354i-1(34), conducted on
this site?
Yes
No
If yes, and your business is not already registered with the Aquifer Protection Program, contact the
local
aquifer protection agent
or DEEP to take appropriate actions.
For more information on the Aquifer Protection Area Program visit the DEEP website at
www.ct.gov/deep/aquiferprotection
or contact the program at 860-424-3020.
6. CONSERVATION OR PRESERVATION RESTRICTION: Is the property subject to a conservation or
preservation restriction?
Yes
No
If Yes, proof of written notice of this application to the holder of such restriction or a letter from the holder
of such restriction verifying that this application is in compliance with the terms of the restriction, must be
submitted as Attachment G.
DEEP-WPED-APP-001
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Part V: Facility or Activity Information
Please check the following to indicate that they are provided in the application:
1.
Principal Raw Materials
Products Produced
Services Provided
2.
SIC Codes
3. Are there other wastes or wastewaters generated on site, or since the last
permit was issued but are not included in this application?
Yes
No
If YES, are the following provided in the application?
Type:
Yes
No
Quality:
Yes
No
Method of disposal:
Yes
No
Note: If other wastes or wastewaters are generated on site, make sure all other wastes
or wastewaters generated on site are listed with the above information provided.
4. Are the names of toxic or hazardous substances or oils listed?
Yes
No
If YES, is the use and maximum quantity used per day listed in the application?
Yes
No
If stored on-site, is the maximum quantity of stored substance indicated on
the application?
Yes
No
4. Are there any Toxic Release Inventory pollutants?
Yes
No
5. Are there any outstanding requirements or compliance schedules?
Yes
No
If YES, are the following provided?
Identification or Requirement (federal, state, or local)
Yes
No
Brief description of Project and Status:
Yes
No
Final Compliance Date (Indicates whether required or projected):
Yes
No
Part VI: Supporting Documents
Have you determined which of the attachments, A through X, are applicable to your
specific activity?
Yes
No
Please check the attachments submitted as verification that all applicable attachments have been submitted with
this application checklist. When submitting any supporting documents, please label the documents as indicated in
this part (e.g., Attachment A, etc.) and be sure to include the applicant's name as indicated in Part III of the
Application Form.
Attachment A: Executive Summary (DEEP-WPED-APP-101)
Please check yes or no to indicate if the following are provided in the application.
1. Applicant Name (as provided in the Application Form):
Yes
No
2. Location of Facility or Activity:
Yes
No
3. Contact Person and Phone Number:
Yes
No
4. Discharge Serial Number(s) (for renewal):
Yes
No
5. Maximum Flow (gallons per day):
Yes
No
6. Category of Discharge:
Yes
No
7. Name(s) of the Receiving Surface water(s):
Yes
No
DEEP-WPED-APP-001
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