"Notice of Intent to Discharge" - New Mexico

Notice of Intent to Discharge is a legal document that was released by the New Mexico Environment Department - a government authority operating within New Mexico.

Form Details:

  • Released on July 11, 2019;
  • The latest edition currently provided by the New Mexico Environment Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download "Notice of Intent to Discharge" - New Mexico

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Ground Water Quality Bureau
New Mexico Environment Department
Notice of Intent to Discharge
Ground Water Quality Bureau
For Department use Only:
Agency Interest Number________
________
PRD Assigned
1.
Name and mailing address of person proposing to discharge (Responsible Person):
_________________________________________
Work Phone: _______________________
_________________________________________
Cell/Home Phone:___________________
_________________________________________
Fax:_______________________________
_________________________________________
Email:_____________________________
2.
Name and Position of person Completing Form:
_________________________________________
Work Phone: _______________________
_________________________________________
Cell/Home Phone:___________________
_________________________________________
Fax:_______________________________
_________________________________________
Email:_____________________________
3.
Name of facility:
__________________________________________________________________________________________
4.
Physical location of the discharge (if applicable, give street address, township, range, section, distance
from closest town or landmark, directions to facility, location map):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
5.
Type of operation generating the discharge (e.g., agricultural facility, domestic wastewater discharge,
industrial discharge, mining operation, etc.):
____________________________________________________________________________________________
6.
Source(s) of the discharge. Describe how the wastewater, sludge, or other discharges processed and/or
disposed at your facility are generated. Identify all sources. Attach additional pages if needed:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
7.
Expected contaminants in the discharge (e.g., nitrate-nitrogen, metals, organic compounds, salts, etc.)
Include estimated concentration if known, and copies of results of laboratory analyses, if available:
_____________________________________________________________________________________________
July 11, 2019
Page 2 of 2
Ground Water Quality Bureau
Notice of Intent
Ground Water Quality Bureau
New Mexico Environment Department
Notice of Intent to Discharge
Ground Water Quality Bureau
For Department use Only:
Agency Interest Number________
________
PRD Assigned
1.
Name and mailing address of person proposing to discharge (Responsible Person):
_________________________________________
Work Phone: _______________________
_________________________________________
Cell/Home Phone:___________________
_________________________________________
Fax:_______________________________
_________________________________________
Email:_____________________________
2.
Name and Position of person Completing Form:
_________________________________________
Work Phone: _______________________
_________________________________________
Cell/Home Phone:___________________
_________________________________________
Fax:_______________________________
_________________________________________
Email:_____________________________
3.
Name of facility:
__________________________________________________________________________________________
4.
Physical location of the discharge (if applicable, give street address, township, range, section, distance
from closest town or landmark, directions to facility, location map):
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
5.
Type of operation generating the discharge (e.g., agricultural facility, domestic wastewater discharge,
industrial discharge, mining operation, etc.):
____________________________________________________________________________________________
6.
Source(s) of the discharge. Describe how the wastewater, sludge, or other discharges processed and/or
disposed at your facility are generated. Identify all sources. Attach additional pages if needed:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
7.
Expected contaminants in the discharge (e.g., nitrate-nitrogen, metals, organic compounds, salts, etc.)
Include estimated concentration if known, and copies of results of laboratory analyses, if available:
_____________________________________________________________________________________________
July 11, 2019
Page 2 of 2
Ground Water Quality Bureau
Notice of Intent
Ground Water Quality Bureau
New Mexico Environment Department
Notice of Intent to Discharge
Ground Water Quality Bureau
For Department use Only:
Agency Interest Number________
________
PRD Assigned
8.
Describe all components of wastewater processing, treatment, storage, and disposal system (e.g., pre-
treatment units, impoundments(s), septic tank/leachfield, etc.). Include sizes, site layout map, plans, and
specifications, etc. if available:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
9.
Estimated maximum daily discharge volume in gallons per day. Provide water usage records or system
sizing criteria if available:
____________________________________________________________________________________________
10. Estimated depth to ground water (ft):________ Source of information_____________________________
11. Current Total Dissolved Solids Concentration in Groundwater___________________________________
Signature: _______________________________________________
Date: ___________________________
Printed name: ____________________________________________
Title: ____________________________
Please return this form to:
NMED Ground Water Quality Bureau
Telephone: 505-827-2900
P.O. Box 5469
Fax:
505-827-2965
Santa Fe, New Mexico 87502-5469
July 11, 2019
Page 2 of 2
Ground Water Quality Bureau
Notice of Intent
Page of 2