"Npdes Individual Permit Renewal Application" - Oregon

Npdes Individual Permit Renewal Application is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • Released on December 5, 2017;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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DEQ USE ONLY
Oregon Department of Environmental Quality
Application #:
RENEWAL APPLICATION
Annual Fee Paid:
National Pollutant Discharge Elimination System
 IND  DOM  OSS  UIC:
Individual Permit
DOC Conf.:
(NPDES-R)
A. REFERENCE INFORMATION
1. Legal Name:
2. Common Name:
3. Permit #:
DEQ File#:
Permit Expiration Date:
4. Facility Physical Address:
City, State, Zip Code:
County:
5. Responsible Official:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
6. Facility Contact:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
7. Invoice to:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
B. REQUIRED INFORMATION
(EPA Form 2A, 2B, 2C, 2E, or 2F must also be submitted with this application)
Attach additional information to describe the following:
1.
The permitted facility, type of wastewater, and primary method of wastewater treatment and disposal.
2.
Any alterations to treatment or disposal methods since the last application was submitted.
3.
Any significant changes in quantity or quality of wastewater since the last application was submitted.
4.
Any significant changes in the management of biosolids, recycled water, or industrial solids since the last application was
submitted.
5.
Any changes anticipated in the near future that would affect wastewater quantity or quality or management of biosolids, recycled
water, or industrial solids.
6.
Progress made to meet the requirements, limitations, and compliance schedules of your permit.
C. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
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.
In addition, I agree to pay the annual
compliance determination fee invoiced annually by DEQ and all other fees required by Oregon Administrative Rules, Chapter 340,
Division 045.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
- 1 -
Rev. 12/5/2017
DEQ USE ONLY
Oregon Department of Environmental Quality
Application #:
RENEWAL APPLICATION
Annual Fee Paid:
National Pollutant Discharge Elimination System
 IND  DOM  OSS  UIC:
Individual Permit
DOC Conf.:
(NPDES-R)
A. REFERENCE INFORMATION
1. Legal Name:
2. Common Name:
3. Permit #:
DEQ File#:
Permit Expiration Date:
4. Facility Physical Address:
City, State, Zip Code:
County:
5. Responsible Official:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
6. Facility Contact:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
7. Invoice to:
Title:
Mailing Address, City, State, Zip Code:
Email Address:
Telephone #:
B. REQUIRED INFORMATION
(EPA Form 2A, 2B, 2C, 2E, or 2F must also be submitted with this application)
Attach additional information to describe the following:
1.
The permitted facility, type of wastewater, and primary method of wastewater treatment and disposal.
2.
Any alterations to treatment or disposal methods since the last application was submitted.
3.
Any significant changes in quantity or quality of wastewater since the last application was submitted.
4.
Any significant changes in the management of biosolids, recycled water, or industrial solids since the last application was
submitted.
5.
Any changes anticipated in the near future that would affect wastewater quantity or quality or management of biosolids, recycled
water, or industrial solids.
6.
Progress made to meet the requirements, limitations, and compliance schedules of your permit.
C. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
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.
In addition, I agree to pay the annual
compliance determination fee invoiced annually by DEQ and all other fees required by Oregon Administrative Rules, Chapter 340,
Division 045.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
- 1 -
Rev. 12/5/2017
NPDES INDIVIDUAL PERMIT RENEWAL APPLICATION INSTRUCTIONS
Please answer all questions. An incomplete application will not be processed.
If the information requested is not applicable, please indicate as such.
A. REFERENCE INFORMATION:
1. Enter the legal name of the applicant. The permit will be issued to the legal name of the applicant and must be the legal
Oregon name (for example, Acme Products, Inc.) or the legal representative of the company if it operates under an
assumed business name (for example, John Smith, dba Acme Products).
** The name must be a legal, active name registered with the Oregon Secretary of State’s Corporation Division unless
otherwise exempt from regulation. Visit the Corporation Division website at
http://www.filinginoregon.com/
or call
503-986-2200.
** If the legal name of the applicant has changed since the initial permit was issued or the permit needs to be transferred to a
new owner, a Name Change/Transfer of Ownership form (enclosed) must also be submitted with this application. This
form is also available by contacting a DEQ regional office listed below or at
https://www.oregon.gov/deq/FilterPermitsDocs/pmttfrappl.pdf.
2. Enter the common name of the facility or operation if different than the legal name.
3. Enter the permit number, DEQ file number (also known as the facility number or site ID number; this number may be
found on the first page of your permit), and expiration date of your current permit.
4. Enter the physical location of the facility (not mailing address), including city, state, zip code, and county.
5. Enter information for the Responsible Official. The Responsible Official is the person that receives official
correspondence from DEQ, such as renewal notices or notices of noncompliance, and may be contacted if there are
questions about this application.
6. Enter information for the Facility Contact if different from the Responsible Official. The Facility Contact is the person
located at the facility that has specific knowledge of the facility or operation under permit (for example, the treatment
plant operator), and may be contacted if there are specific questions about this application.
7. Enter invoicing information for billing purposes if different from the Responsible Official (for example, "Invoice To:
Business Office - Accounts Payable").
B. REQUIRED INFORMATION:
1 - 5. Attach additional information as indicated.
In addition, EPA Form 2A, 2B, 2C, 2E, or 2F must be submitted with this application depending on the type of facility or
operation to be permitted. The correct form is enclosed in this application packet or may be obtained by contacting the
appropriate DEQ regional office listed at the bottom of this page.
C. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE:
The signature of a legally authorized representative must be provided in order to process this application.
Definition of Legally Authorized Representative:
See 40 CFR § 122.22 for more detail. Please also provide the information requested in brackets [ ]
♦ Corporation – President, secretary, treasurer, vice-president, or any person who performs principal business functions;
or a manager of one or more facilities employing more than 250 persons or having gross annual sales or expenditures
exceeding $25 million that is authorized in accordance to corporate procedure to sign such documents.
♦ Partnership – General partner [list of general partners, their addresses and telephone numbers].
♦ Sole Proprietorship – Owner(s) [each owner must sign the application].
♦ City, County, State, Federal, or other Public Facility – Principal executive officer or ranking elected official.
♦ Limited Liability Company – Member.
♦ Trusts – Acting trustee [list of trustees, their addresses and telephone numbers].
FEE AND APPLICATION SUBMITTAL:
Please see the cover letter enclosed with this form or call the appropriate regional office below for fee information and to
determine where to send this application. This application must be submitted at least 180 days prior to the expiration date of
your current permit.
Send this form and fee to the appropriate DEQ regional office:
Make your check payable to the Oregon Department of Environmental Quality
DEQ Northwest Region
DEQ Western Region
DEQ Eastern Region
700 NE Multnomah St., Suite 600
4026 Fairview Industrial Dr. SE
800 SE Emigrant Ave., Suite 330
Portland, OR 97232
Salem, OR 97302
Pendleton, OR 97801
503-229-5263 or 1-800-452-4011
503-378-8240 or 1-800-349-7677
541-276-4063 or 1-800-304-3513
Rev. 12/5/2017
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