State Form 55919 "Notice of Intent (Noi) Letter for Ing340000 Petroleum Products Terminals General Npdes Permit" - Indiana

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

Form Details:

  • Released on December 1, 2020;
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NOTICE OF INTENT (NOI) LETTER
A scanned copy of all completed documents may be sent via
e-mail to OWQ@idem.IN.gov. Online fee payments may be
FOR ING340000 PETROLEUM
made at www.in.gov/idem/6973.htm.
PRODUCTS TERMINALS
Alternatively, this form, fee payment, and required
GENERAL NPDES PERMIT
attachments may be mailed to:
State Form 55919 (R / 12-20)
Indiana Department of Environmental Management
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Office of Water Quality, Permits Administration Section
100 North Senate Avenue, IGCN Room 1255
Indianapolis, IN 46204-2251
INSTRUCTIONS
This form must be used to apply for coverage under the General NPDES Permit for wastewater from petroleum products terminals
pursuant to NPDES Permit No. ING340000.
This form must be completed fully.
If you do not use a computer to complete this form, please type or print in ink. Do not use white-out to correct errors.
Further item-specific instructions are provided in Appendix A at the end of this form.
For questions regarding this form, the required attachments, and permit requirements, contact IDEM General NPDES Permits at
(317) 232-8704 or (800) 451-6027, ext 28704 (within Indiana).
ELIGIBILITY REQUIREMENTS
APPLICATION TYPE
“Petroleum products terminal” refers to a facility where petroleum products are supplied by pipeline or
NEW
barge and where petroleum products are stored in above-ground tanks, or are transferred to trucks
for transport to other locations, or both. This general permit authorizes new and existing discharges,
RENEW
described as follows, from petroleum products terminals to surface waters of the State of Indiana:
MODIFICATION
a)
discharges of hydrostatic test waters from storage tanks and onsite pipelines which may have
been used for the storage and/or transfer or conveyance of crude oil or liquid petroleum
PERMIT NUMBER, IF APPLICABLE
products ;
b)
discharges of stormwater runoff from the diked containment areas of these storage tanks; and
c)
discharges of tank bottom water from these storage tanks. This permit does not, however,
OTHER PERMIT NUMBER(S)
authorize the discharge of any accumulated solids or sludges from the tank bottoms. The
APPLICABLE TO SITE
permittee is required to properly remove and dispose of such solids in accordance with
327 IAC 5-5-2.
The following incidental discharges may also be authorized if properly characterized in this NOI:
“fire hydrant flushings; potable water sources, including waterline flushings; uncontaminated
ground water or spring water; uncontaminated air conditioning or compressor condensate;
vehicle washwaters uncontaminated with detergents or solvents; and runoff from foundation or
footing drains where flows are not contaminated with process materials such as solvents”.
DESCRIPTION OF PROPOSED
MODIFICATION, IF APPLICABLE
Discharges NOT authorized by this permit include the following:
1)
direct discharges into waters that are designated as an Outstanding National Resource Water
(ONRW) defined at IC 13-11-2-149.5 or an Outstanding State Resource Water (OSRW) defined
at IC 13-11-2-149.6 and listed at 327 IAC 2-1.3-3(d). s;
2)
discharges to a receiving stream when the discharge results in an increase in the ambient
concentration of a pollutant which contributes to the impairment of the receiving stream for that
pollutant as identified on the current 303(d) list of impaired waters;
3)
discharges containing water treatment additives (WTAs) which have not received prior written
approval from IDEM for the specific additive, use, and dosage at the particular facility for which
the Notice of Intent (NOI) is submitted;
4)
discharges resulting from the cleaning of tanks or pipelines;
5)
storm water discharges associated with construction activity;
6)
discharges to combined or sanitary sewer systems;
7)
discharges that are commingled with hazardous wastes or hazardous materials;
8)
discharges of domestic or sanitary wastewater and
9)
discharges for which the Commissioner requests an individual permit application.
By checking this box, I certify that this facility meets all eligibility requirements of
this general permit
.
PART A: FACILITY INFORMATION
1. FACILITY NAME (See Appendix A)
2. FACILITY MAILING ADDRESS
3. FACILITY PHYSICAL LOCATION
STREET ADDRESS (number and street)
STREET ADDRESS (number and street)
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
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Reset Form
NOTICE OF INTENT (NOI) LETTER
A scanned copy of all completed documents may be sent via
e-mail to OWQ@idem.IN.gov. Online fee payments may be
FOR ING340000 PETROLEUM
made at www.in.gov/idem/6973.htm.
PRODUCTS TERMINALS
Alternatively, this form, fee payment, and required
GENERAL NPDES PERMIT
attachments may be mailed to:
State Form 55919 (R / 12-20)
Indiana Department of Environmental Management
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Office of Water Quality, Permits Administration Section
100 North Senate Avenue, IGCN Room 1255
Indianapolis, IN 46204-2251
INSTRUCTIONS
This form must be used to apply for coverage under the General NPDES Permit for wastewater from petroleum products terminals
pursuant to NPDES Permit No. ING340000.
This form must be completed fully.
If you do not use a computer to complete this form, please type or print in ink. Do not use white-out to correct errors.
Further item-specific instructions are provided in Appendix A at the end of this form.
For questions regarding this form, the required attachments, and permit requirements, contact IDEM General NPDES Permits at
(317) 232-8704 or (800) 451-6027, ext 28704 (within Indiana).
ELIGIBILITY REQUIREMENTS
APPLICATION TYPE
“Petroleum products terminal” refers to a facility where petroleum products are supplied by pipeline or
NEW
barge and where petroleum products are stored in above-ground tanks, or are transferred to trucks
for transport to other locations, or both. This general permit authorizes new and existing discharges,
RENEW
described as follows, from petroleum products terminals to surface waters of the State of Indiana:
MODIFICATION
a)
discharges of hydrostatic test waters from storage tanks and onsite pipelines which may have
been used for the storage and/or transfer or conveyance of crude oil or liquid petroleum
PERMIT NUMBER, IF APPLICABLE
products ;
b)
discharges of stormwater runoff from the diked containment areas of these storage tanks; and
c)
discharges of tank bottom water from these storage tanks. This permit does not, however,
OTHER PERMIT NUMBER(S)
authorize the discharge of any accumulated solids or sludges from the tank bottoms. The
APPLICABLE TO SITE
permittee is required to properly remove and dispose of such solids in accordance with
327 IAC 5-5-2.
The following incidental discharges may also be authorized if properly characterized in this NOI:
“fire hydrant flushings; potable water sources, including waterline flushings; uncontaminated
ground water or spring water; uncontaminated air conditioning or compressor condensate;
vehicle washwaters uncontaminated with detergents or solvents; and runoff from foundation or
footing drains where flows are not contaminated with process materials such as solvents”.
DESCRIPTION OF PROPOSED
MODIFICATION, IF APPLICABLE
Discharges NOT authorized by this permit include the following:
1)
direct discharges into waters that are designated as an Outstanding National Resource Water
(ONRW) defined at IC 13-11-2-149.5 or an Outstanding State Resource Water (OSRW) defined
at IC 13-11-2-149.6 and listed at 327 IAC 2-1.3-3(d). s;
2)
discharges to a receiving stream when the discharge results in an increase in the ambient
concentration of a pollutant which contributes to the impairment of the receiving stream for that
pollutant as identified on the current 303(d) list of impaired waters;
3)
discharges containing water treatment additives (WTAs) which have not received prior written
approval from IDEM for the specific additive, use, and dosage at the particular facility for which
the Notice of Intent (NOI) is submitted;
4)
discharges resulting from the cleaning of tanks or pipelines;
5)
storm water discharges associated with construction activity;
6)
discharges to combined or sanitary sewer systems;
7)
discharges that are commingled with hazardous wastes or hazardous materials;
8)
discharges of domestic or sanitary wastewater and
9)
discharges for which the Commissioner requests an individual permit application.
By checking this box, I certify that this facility meets all eligibility requirements of
this general permit
.
PART A: FACILITY INFORMATION
1. FACILITY NAME (See Appendix A)
2. FACILITY MAILING ADDRESS
3. FACILITY PHYSICAL LOCATION
STREET ADDRESS (number and street)
STREET ADDRESS (number and street)
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
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4. PARENT COMPANY/OWNER’S COMPLETE MAILING ADDRESS
5. FACILITY SIC & NAICS CODES
6. FACILITY COUNTY
(See Appendix A)
COMPANY NAME
STREET ADDRESS (number and street)
7. LATITUDE AND LONGITUDE OF APPROXIMATE CENTER OF FACILITY SITE
(See Appendix A)
Latitude
Longitude
degree
minute
second
degree
minute
second
CITY
STATE
ZIP CODE
8. What is the nature of the primary business conducted at the facility or site? (Example: petroleum bulk storage terminal)
9. Provide a brief description of the facility operations that result in the discharge. (Example: Stormwater runoff from diked areas containing crude oil
storage tanks, plus occasional hydrostatic testing of new tanks.) Provide information about the method(s) used for flow measurement.
PART B: CONTACT INFORMATION FOR RESPONSIBLE OFFICIAL (AUTHORIZED NOI SIGNATORY)
Provide information regarding the responsible official who has the authorization to sign this NOI in accordance with 40 CFR 122.22. If the
responsible official wishes to delegate signatory authority for reports and other correspondence related to General NPDES permit coverage,
delegation must be made in writing to IDEM. This delegation of authority may occur either via this NOI or via a separate letter (signed and dated by
the responsible official) which shall be submitted via e-mail to
OWQ@idem.IN.gov
or to the address at the top of the front page of this form.
10. NAME OF RESPONSIBLE OFFICIAL
11. DELEGATED SIGNATORY PERSON (OR POSITION) TO SIGN
REPORTS AND FILE ADDITIONAL NOI CONTENT REQUIREMENTS
RESPONSIBLE OFFICIAL’S TITLE
DELEGATED SIGNATORY PERSON’S TITLE or POSITION
RESPONSIBLE OFFICIAL’S TELEPHONE NUMBER
DELEGATED SIGNATORY PERSON’S TELEPHONE NUMBER
RESPONSIBLE OFFICIAL’S PERSON’S E-MAIL ADDRESS
DELEGATED SIGNATORY PERSON’S E-MAIL ADDRESS
PART C: OTHER CONTACT INFORMATION
12.
DISCHARGE MONITORING REPORTS
CONTACT PERSON AND COMPANY NAME
CONTACT AND MAILING INFORMATION
CONTACT TELEPHONE NUMBER
STREET ADDRESS (number and street)
CONTACT E-MAIL ADDRESS
CITY
STATE
ZIP CODE
13.
ANNUAL FEE AND FINANCIAL
CONTACT PERSON AND COMPANY NAME
CONTACT AND BILLING ADDRESS
CONTACT TELEPHONE NUMBER
STREET ADDRESS (number and street)
CONTACT E-MAIL ADDRESS
CITY
STATE
ZIP CODE
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14.
OPERATOR CONTACT AND MAILING INFORMATION
CONTACT PERSON AND COMPANY NAME
CONTACT TELEPHONE NUMBER
STREET ADDRESS (number and street)
CONTACT E-MAIL ADDRESS
CITY
STATE
ZIP CODE
PART D: SOURCE WATER INFORMATION
15. Please provide information regarding the volume of water in millions of gallons per day (MGD) which you propose to withdraw on a daily basis from
each of the following sources for use for the hydrostatic testing of tanks or onsite pipelines to be covered by this general permit.
WELL WATER
SURFACE WATER
PUBLIC WATER SUPPLY
UNITS
MGD
PART E: OUTFALL INFORMATION
Provide the following information for all outfalls/discharges to be covered by this general permit. You may attach additional sheets if necessary.
16.
17.
18. RECEIVING
19.
20.
FOR ANY DISCHARGE INTO
ANTICIPATED DAILY VOLUME
OUTFALL
LATITUDE
LONGITUDE
WATER
A STORM SEWER IDENTIFY THE
OF DISCHARGE in MGD AND
NUMBER
deg
min
sec.
deg.
min.
sec.
STORM SEWER OWNER.
METHOD OF DETERMINATION OF
(See Appendix A)
(See Appendix A)
VOLUME
PART F: POTENTIALLY ALLOWABLE NON-STORM WATER CONTRIBUTIONS
21 Storm water impacted by the following non-storm water sources is permitted to be discharged through the outfalls listed in Part E above: “firefighting
activities; fire hydrant flushings; potable water sources, including waterline flushings; uncontaminated ground water or spring water; uncontaminated air
conditioning or compressor condensate; vehicle wash waters uncontaminated with detergents or solvents; and runoff from foundation or footing drains
where flows are not contaminated with process materials such as solvents”.
Please check the appropriate boxes below to indicate which of these sources are expected to discharge through each outfall at this site.
OUTFALL
Firefighting
Hydrant flushings
Potable sources/
Uncontaminated
Uncontaminated air
Uncontaminated
Uncontaminated
NUMBER
Activities
waterline flushings
ground/spring water
conditioning or
vehicle washwaters
discharges from
compressor
foundation/ footing
condensate
drains
PART G: TYPE(S) OF PETROLEUM PRODUCTS STORED AT THE SITE IN PROXIMITY OF EACH OUTFALL
22. For each outfall indicate the types of petroleum products which are typically stored at the site.
OUTFALL
GASOLINE
NUMBER 6
CRUDE OIL
NUMBER 2 FUEL
LUBRICATING
AVAIATIO
JET FUEL
SOLVENTS
CLEANING/
NUMBER
FUEL OIL
OIL / DIESEL FUEL
OILS
N GAS
(JP-4)
DISINFECTANT
USES
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PART H: EFFLUENT CHARACTERISTICS FOR EACH OUTFALL TO BE COVERED BY THIS PERMIT
Please provide the following information for each outfall/discharge to be covered by this general permit. If you have more than one outfall you may
use the additional table in Appendix B at the end of this form. Insert the outfall number for each set of effluent data.
OUTFALL NUMBER:
TABLE H-1 EFFLUENT CHARACTERISTICS FOR ALL DISCHARGES TO BE COVERED UNDER THIS PERMIT
The following table is to be completed for any of the types of wastewater that are covered by this general permit. Please provide the following
information for each outfall/discharge to be covered by this general permit. If you have more than one outfall you may use the additional tables in
Appendix B at the end of this form. Insert the outfall number for each set of effluent data.
A.
Existing Sources – Provide measurements for the parameters listed below. You must use, or require your contract laboratory to use, an
analytical method with a detection level low enough to provide a detectable value for the pollutant of concern. Please provide information on
the method used and detection limit achieved by the laboratory. (See Appendix A)
B.
New Dischargers – Provide estimates for the parameters listed below. In lieu of the number of measurements taken, provide the source of
the estimated values. (See Appendix A)
(1)
(2)
25. (3) or
(4)
Analytical Method
TABLE H-1 PARAMETERS
23.
Maximum
24.
Average Daily
(List method used and its
Number of
Source of
detection limit.)
Daily Value
Value (last year)
Measurements
Estimate
Method
Detection
Taken
(if new
Limit
Concentration
Units
Concentration
Units
(last year)
discharger)
Total Suspended Solids (TSS)
Total Residual Chlorine (if chlorinated
water is used)
Oil and Grease
Discharge Flow
VALUE in MGD
VALUE IN MGD
pH (S.U.)
MINIMUM
MAXIMUM
TABLE H-2 ADDITIONAL EFFLUENT CHARACTERISTICS FOR DISCHARGES OF STORM WATER
Please provide the following information for each outfall/discharge of storm water runoff to be covered by this general permit.
A.
Existing Sources – Provide measurements for the parameters listed below. You must use, or require your contract laboratory to use, an
analytical method with a detection level low enough to provide a detectable value for the pollutant of concern. Please provide information on
the method used and detection limit achieved by the laboratory. (See Appendix A)
B.
New Dischargers – Provide estimates for the parameters listed below. In lieu of the number of measurements taken, provide the source of
the estimated values. (See Appendix A)
(1)
(2)
25. (3) or
(4)
Analytical Method
(List method used and its
TABLE H-2 PARAMETERS
23.
Maximum
24.
Average Daily
Number of
Source of
detection limit.)
Daily Value
Value (last year)
Measurements
Estimate
Method
Detection
Taken
(if new
Limit
Concentration
Units
Concentration
Units
(last year)
discharger)
Ammonia (as N)
Lead
Benzene
BTEX
Naphthalene
Chemical Oxygen Demand (COD)
4 of 12
TABLE H-3 ADDITIONAL EFFLUENT CHARACTERISTICS FOR DISCHARGES OF HYDROSTATIC TEST WATER FOR
EXISTING TANKS OR PIPELINES OR FOR DISCHARGES OF TANK BOTTOM WATER
Please provide the following information for each outfall/discharge of tank bottom water or hydrostatic test water involving existing tanks or pipelines
to be covered by this general permit.
A.
Existing Sources – Provide measurements for the parameters listed below. You must use, or require your contract laboratory to use, an
analytical method with a detection level low enough to provide a detectable value for the pollutant of concern. Please provide information on
the method used and detection limit achieved by the laboratory. (See Appendix A)
B.
New Dischargers – Provide estimates for the parameters listed below. In lieu of the number of measurements taken, provide the source of
the estimated values. (See Appendix A)
(1)
(2)
25. (3) or
(4)
Analytical Method
TABLE H-3 PARAMETERS
23.
Maximum
24.
Average Daily
(List method used and its
Number of
Source of
detection limit.)
Daily Value
Value (last year)
Measurements
Estimate
Method
Detection
Taken
(if new
Limit
Concentration
Units
Concentration
Units
(last year)
discharger)
Ammonia (as N)
Lead
Cyanide, free
Cyanide, total
Benzene
BTEX
Naphthalene
Chemical Oxygen Demand (COD)
PAHs
Total Organic Carbon
Total Volatile Organic Compounds
PART I: WATER TREATMENT ADDITIVES
26. Please fill out the following additional information about the discharge from each outfall. Note that the only additives that may be used
under this permit are those that have been previously approved for use at this site by the Indiana Department of Environmental Management
and that are already in use at the time of this submittal. You may attach additional sheets if necessary. (See Appendix A for information about
applying for approval of use for WTAs.)
OUTFALL
WATER TREATMENT ADDITIVES (WTAs) TO BE USED
NUMBER
(ATTACH A COPY OF IDEM APPROVAL LETTER FOR EACH WTA TO BE USED.)
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