Form B (MO780-1512) "Application for Operating Permit for Facilities That Receive Primarily Domestic Waste and Have a Design Flow Less Than or Equal to 100,000 Gallons Per Day" - Missouri

This version of the form is not currently in use and is provided for reference only.
Download this version of Form B (MO780-1512) for the current year.

What Is Form B (MO780-1512)?

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

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • 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 fillable version of Form B (MO780-1512) by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

ADVERTISEMENT
ADVERTISEMENT

Download Form B (MO780-1512) "Application for Operating Permit for Facilities That Receive Primarily Domestic Waste and Have a Design Flow Less Than or Equal to 100,000 Gallons Per Day" - Missouri

Download PDF

Fill PDF online

Rate (4.5 / 5) 24 votes
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR AGENCY USE ONLY
WATER PROTECTION PROGRAM
CHECK NUMBER
FORM B: APPLICATION FOR OPERATING PERMIT FOR
FACILITIES THAT RECEIVE PRIMARILY DOMESTIC WASTE AND
DATE RECEIVED
FEE SUBMITTED
HAVE A DESIGN FLOW LESS THAN OR EQUAL TO 100,000
JETPAY CONFIRMATION NUMBER
GALLONS PER DAY
READ THE ACCOMPANYING INSTRUCTIONS BEFORE COMPLETING THIS FORM
1. THIS APPLICATION IS FOR:
An operating permit for a new or unpermitted facility.
Construction Permit #
(Include completed antidegradation review or request for antidegradation review, see instructions)
A new site-specific operating permit formerly general permit #MOG
A site-specific operating permit renewal:
Permit #MO-
Expiration Date
A site-specific operating permit modification:
Permit #MO-
Reason:
General permit (NON-POTWs) (MOGD –discharging < 50,000 GPD or MOG823 – Land Application of Domestic Wastewater):
Permit #MO-
Expiration Date
1.1
Is the appropriate fee included with the application (see instructions for appropriate fee)?
YES
NO
2. FACILITY
NAME
TELEPHONE NUMBER WITH AREA CODE
ADDRESS (PHYSICAL)
CITY
STATE
ZIP CODE
2.1
Legal description:
Sec.
, T
, R
County
2.2
UTM Coordinates Easting (X):
Northing (Y):
For Universal Transverse Mercator (UTM), Zone 15 North referenced to North American Datum 1983 (NAD83)
2.3
Name of receiving stream:
2.4
Number of outfalls:
Wastewater outfalls:
Stormwater outfalls:
Instream monitoring sites:
3. OWNER:
NAME
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
3.1
Request review of draft permit prior to public notice?
YES
NO
3.2
Are you a publicly owned treatment works?
YES
NO
See:
https://dnr.mo.gov/forms/780-2511-f.pdf
If yes, please attach the Financial Questionnaire.
3.3
Are you a privately owned treatment works?
YES
NO
3.4
Are you a privately owned treatment facility regulated by the Public Service Commission?
YES
NO
4. CONTINUING AUTHORITY:
NAME
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
If the continuing authority is different than the owner, include a copy of the contract agreement between the two parties and a
description of the responsibilities of both parties within the agreement.
5. OPERATOR
NAME
TITLE
CERTIFICATE NUMBER
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
6. FACILITY CONTACT
NAME
TITLE
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
MO 780-1512 (10-20)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
FOR AGENCY USE ONLY
WATER PROTECTION PROGRAM
CHECK NUMBER
FORM B: APPLICATION FOR OPERATING PERMIT FOR
FACILITIES THAT RECEIVE PRIMARILY DOMESTIC WASTE AND
DATE RECEIVED
FEE SUBMITTED
HAVE A DESIGN FLOW LESS THAN OR EQUAL TO 100,000
JETPAY CONFIRMATION NUMBER
GALLONS PER DAY
READ THE ACCOMPANYING INSTRUCTIONS BEFORE COMPLETING THIS FORM
1. THIS APPLICATION IS FOR:
An operating permit for a new or unpermitted facility.
Construction Permit #
(Include completed antidegradation review or request for antidegradation review, see instructions)
A new site-specific operating permit formerly general permit #MOG
A site-specific operating permit renewal:
Permit #MO-
Expiration Date
A site-specific operating permit modification:
Permit #MO-
Reason:
General permit (NON-POTWs) (MOGD –discharging < 50,000 GPD or MOG823 – Land Application of Domestic Wastewater):
Permit #MO-
Expiration Date
1.1
Is the appropriate fee included with the application (see instructions for appropriate fee)?
YES
NO
2. FACILITY
NAME
TELEPHONE NUMBER WITH AREA CODE
ADDRESS (PHYSICAL)
CITY
STATE
ZIP CODE
2.1
Legal description:
Sec.
, T
, R
County
2.2
UTM Coordinates Easting (X):
Northing (Y):
For Universal Transverse Mercator (UTM), Zone 15 North referenced to North American Datum 1983 (NAD83)
2.3
Name of receiving stream:
2.4
Number of outfalls:
Wastewater outfalls:
Stormwater outfalls:
Instream monitoring sites:
3. OWNER:
NAME
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
3.1
Request review of draft permit prior to public notice?
YES
NO
3.2
Are you a publicly owned treatment works?
YES
NO
See:
https://dnr.mo.gov/forms/780-2511-f.pdf
If yes, please attach the Financial Questionnaire.
3.3
Are you a privately owned treatment works?
YES
NO
3.4
Are you a privately owned treatment facility regulated by the Public Service Commission?
YES
NO
4. CONTINUING AUTHORITY:
NAME
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
If the continuing authority is different than the owner, include a copy of the contract agreement between the two parties and a
description of the responsibilities of both parties within the agreement.
5. OPERATOR
NAME
TITLE
CERTIFICATE NUMBER
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
6. FACILITY CONTACT
NAME
TITLE
EMAIL ADDRESS
TELEPHONE NUMBER WITH AREA CODE
ADDRESS
CITY
STATE
ZIP CODE
MO 780-1512 (10-20)
7. DESCRIPTION OF FACILITY
7.1 Process Flow Diagram or Schematic: Provide a diagram showing the processes of the treatment plant. Show all of the
treatment units, including disinfection (e.g. – chlorination and dechlorination), influents, and outfalls. Specify where samples are
taken. Indicate any treatment process changes in the routing of wastewater during dry weather and peak wet weather. Include a
brief narrative description of the diagram.
Attach sheets as necessary.
7.2 Attach an aerial photograph or USGS topographic map showing the location of the facility and outfall.
Please see the following website:
https://modnr.maps.arcgis.com/apps/webappviewer/index.html?id=1d81212e0854478ca0dae87c33c8c5ce
MO 780-1512 (10-20)
8. ADDITIONAL FACILITY INFORMATION
8.1
Number of people presently connected or population equivalent (P.E.)
Design P.E.
8.2
Connections to the facility:
Number of units presently connected:
Residential:
Commercial:
Industrial:
8.3
Design flow:
Actual flow:
8.4
Will discharge be continuous through the year?
Yes
No
Discharge will occur during the following months:
________________________
How many days of the week will discharge occur?
8.5
Is industrial wastewater discharged to the facility?
Yes
No
If yes, attach a list of the industries that discharge to your facility
8.6
Does the facility accept or process leachate from landfills?
Yes
No
8.7
Is wastewater land applied?
Yes
No
See:
https://dnr.mo.gov/forms/780-1686-f.pdf
If yes, attach Form I.
8.8
Does the facility discharge to a losing stream or sinkhole?
Yes
No
8.9
Has a wasteload allocation study been completed for this facility?
Yes
No
9. LABORATORY CONTROL INFORMATION
LABORATORY WORK CONDUCTED BY PLANT PERSONNEL
Lab work conducted outside of plant.
Yes
No
Push-button or visual methods for simple test such as pH, settlable solids.
Yes
No
Additional procedures such as dissolved oxygen, chemical
oxygen demand, biological oxygen demand, titrations, solids, volatile content.
Yes
No
More advanced determinations such as BOD seeding procedures,
fecal coliform/E. coli, nutrients (including Ammonia), Oil & Grease, \ total oils, phenols, etc.
Yes
No
Highly sophisticated instrumentation, such as atomic absorption and gas chromatograph.
Yes
No
10. COLLECTION SYSTEM
10.1 Are there any municipal satellite collection systems connected to this facility? _____ Yes
______ No
If yes, please list all connected to this facility, contact phone number and length of each collection system
LENGTH OF SYSTEM
FACILITY NAME
CONTACT PHONE NUMBER
(FEET OR MILES)
10.2
Length of pipe in the sewer collection system? (If available, include totals from satellite collection systems)
Feet, or
Miles (either unit is appropriate)
10.3
Does significant infiltration occur in the collection system?
Yes
No
If yes, briefly explain any steps underway or planned to minimize inflow and infiltration:
MO 780-1512 ( 10-20)
11. BYPASSING
Does any bypassing occur in the collection system or at the treatment facility?
Yes
No
If yes, explain:
12. SLUDGE HANDLING, USE AND DISPOSAL
12.1
Is the sludge a hazardous waste as defined by 10 CSR 25?
Yes
No
12.2
Sludge production, including sludge received from others:
Design dry tons/year
Actual dry tons/year
12.3
Capacity of sludge holding structures:
Sludge storage provided:
cubic feet;
days of storage;
average percent solids of sludge;
No sludge storage is provided.
Sludge is stored in lagoon.
12.4
Type of Storage:
Holding tank
Building
Basin
Lagoon
Concrete Pad
Other (Describe)
12.5
Sludge Treatment:
Anaerobic Digester
Lagoon
Composting
Storage Tank
Aerobic Digester
Other (Attach description)
Lime Stabilization
Air or Heat Drying
12.6
Sludge Use or Disposal:
Land Application
Surface Disposal (Sludge Disposal Lagoon, Sludge held for more than two years)
Contract Hauler
Hauled to Another treatment facility
Incineration
Sludge Retained in Wastewater treatment lagoon
Solid waste landfill
12.7
Person responsible for hauling sludge to disposal facility:
By applicant
By others (complete below)
NAME
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON
TELEPHONE NUMBER WITH AREA CODE
PERMIT NO.
MO-
12.8
Sludge use or disposal facility
By applicant
By others (Complete below.)
NAME
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON
TELEPHONE NUMBER WITH AREA CODE
PERMIT NO.
MO-
12.9
Does the sludge or biosolids disposal comply with federal sludge regulations under 40 CFR 503?
Yes
No
(Explain)
MO 780-1512 (10-20)
13. ELECTRONIC DISCHARGE MONITORING REPORT (eDMR) SUBMISSION SYSTEM
Per 40 CFR Part 127, National Pollutant Discharge Elimination System (NPDES) Electronic Reporting Rule, reporting of effluent
limits and monitoring shall be submitted by the permittee via an electronic system to ensure a timely, complete, accurate, and
nationally- consistent set of data. One of the following options must be checked in order for this application to be considered
complete. Visit
https://dnr.mo.gov/env/wpp/edmr.htm
to for information on the Department’s eDMR system and how to register.
I will register an account online to participate in the Department’s eDMR system through the Missouri Gateway for Environmental
Management (MoGEM) before any reporting is due, in compliance with the Electronic Reporting Rule.
I have already registered an account online to participate in the Department’s eDMR system through MoGEM.
I have submitted a written request for a waiver from electronic reporting. See instructions for further information regarding
waivers.
The permit I am applying for does not require the submission of discharge monitoring reports.
14. JETPAY
Permit fees may be payed online by credit card or eCheck through a system called JetPay. Use the URL provided to access JetPay
and make an online payment.
New Site Specific Permit:
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/591/
Construction Permits:
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/592/
Modification Fee:
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/596/
New General Domestic WW:
https://magic.collectorsolutions.com/magic-ui/payments/mo-natural-resources/772/
15. CERTIFICATION
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.
NAME (TYPE OR PRINT)
OFFICIAL TITLE
TELEPHONE NUMBER WITH AREA CODE
SIGNATURE
DATE SIGNED
MO 780-1512 (10-20)