"Application for New Water Pollution Control Facilities Individual Permit" - Oregon

Application for New Water Pollution Control Facilities Individual Permit is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

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DEQ USE ONLY
DEQ USE ONLY
APPLICATION FOR NEW
Application #: _____________
Date Received: ______________
WATER POLLUTION CONTROL
File #: ___________________
Amount Received: _______________
FACILITIES INDIVIDUAL PERMIT
Amt. Due (if any): ____________
Mail ID #2 / #9: _______________
(WPCF-N)
LLID / RM: ________________
Check #: ____________________
(See pages
4 – 7
for detailed
ACD Fee Paid: _____________
Deposit #: __________________
instructions)
Doc Conf:_________________
Receipt #: ___________________
Notes:
☐ IND ☐ DOM
State of Oregon
☐ OSS Surcharge: ___________
Department of Environmental Quality
A. Reference Information
1. Legal Name of Applicant: _______________________________________________________________________
2. Is the applicant the owner of the operation or facility? ☐ Yes ☐ No
3. Legal Status of Applicant: ☐ Federal ☐ State ☐ Public ☐ Private ☐ Other:_____________________________
4. Name of Facility (if different than legal name): ______________________________________________________
5. Facility SIC Code: ______________________________ or NAICS Code: _________________________________
B. Facility Location
1. Physical Street Address: ________________________________________________________________________
City: ___________________________ State: _____ Zip Code: ________ County: ________________________
Latitude:
Deg.
Min.
Sec.
2.
Longitude:
Deg.
Min.
Sec.
3. Township: ____________________ Section: _______________ Range: ______________ Tax Lot#: ___________
C. Facility Contacts
1. Responsible Official
Full Name: ____________________________________________ Telephone #: ___________________________
Mailing Address: ________________________ City: _____________________ State: ____ Zip Code: ________
Email Address: ________________________________________________________________________________
2. Facility Contact
Full Name: ____________________________________________ Telephone #: ___________________________
Mailing Address: ________________________ City: _____________________ State: ____ Zip Code: ________
Email Address: ________________________________________________________________________________
3. Invoice Contact
Full Name: ____________________________________________ Telephone #: ___________________________
Billing Address: ________________________ City: _____________________ State: ____ Zip Code: _________
Email Address: ________________________________________________________________________________
20180626~TLB
1
DEQ USE ONLY
DEQ USE ONLY
APPLICATION FOR NEW
Application #: _____________
Date Received: ______________
WATER POLLUTION CONTROL
File #: ___________________
Amount Received: _______________
FACILITIES INDIVIDUAL PERMIT
Amt. Due (if any): ____________
Mail ID #2 / #9: _______________
(WPCF-N)
LLID / RM: ________________
Check #: ____________________
(See pages
4 – 7
for detailed
ACD Fee Paid: _____________
Deposit #: __________________
instructions)
Doc Conf:_________________
Receipt #: ___________________
Notes:
☐ IND ☐ DOM
State of Oregon
☐ OSS Surcharge: ___________
Department of Environmental Quality
A. Reference Information
1. Legal Name of Applicant: _______________________________________________________________________
2. Is the applicant the owner of the operation or facility? ☐ Yes ☐ No
3. Legal Status of Applicant: ☐ Federal ☐ State ☐ Public ☐ Private ☐ Other:_____________________________
4. Name of Facility (if different than legal name): ______________________________________________________
5. Facility SIC Code: ______________________________ or NAICS Code: _________________________________
B. Facility Location
1. Physical Street Address: ________________________________________________________________________
City: ___________________________ State: _____ Zip Code: ________ County: ________________________
Latitude:
Deg.
Min.
Sec.
2.
Longitude:
Deg.
Min.
Sec.
3. Township: ____________________ Section: _______________ Range: ______________ Tax Lot#: ___________
C. Facility Contacts
1. Responsible Official
Full Name: ____________________________________________ Telephone #: ___________________________
Mailing Address: ________________________ City: _____________________ State: ____ Zip Code: ________
Email Address: ________________________________________________________________________________
2. Facility Contact
Full Name: ____________________________________________ Telephone #: ___________________________
Mailing Address: ________________________ City: _____________________ State: ____ Zip Code: ________
Email Address: ________________________________________________________________________________
3. Invoice Contact
Full Name: ____________________________________________ Telephone #: ___________________________
Billing Address: ________________________ City: _____________________ State: ____ Zip Code: _________
Email Address: ________________________________________________________________________________
20180626~TLB
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D. General Information
1. Briefly describe the proposed facility, type of wastewater, and primary method of wastewater treatment and
disposal:
2. Does the proposed facility include a graywater reuse and disposal system?
☐ Yes
☐ No
3. Is the proposed facility located within the service boundary of a municipal sanitary sewerage system?
☐ *Yes ☐ No
*If “Yes”, explain why this discharge is not being connected to a sanitary sewer.
4. Does the proposed facility described in D.1, discharge wastewater to an Underground Injection Control (UIC)
System?
☐ Yes
☐ No
5. Is there any other wash water or wastewater that will be or is being discharged to a UIC system not described in
D.1?
☐ *Yes ☐ No
*If “Yes”, also provide the information required in Section C, Preliminary Engineering Report / Facility Plan for
each UIC.
6. Does or will stormwater at the facility be drained to a UIC system other than described by this application?
☐ *Yes ☐ No
*If “Yes”, also complete UIC Registration Form: Stormwater Drainage Systems (enclosed with this application.
E. Other DEQ or Public Agency Permits
List all other DEQ or public agency permits issued to or applied for this project:
F. Preliminary Engineering Report / Facility Plan
Attach two copies of a Preliminary Engineering Report or Facility Plan Report that fully describes the proposed
project using written discussion, maps, diagrams, and any other necessary materials. The report must contain
the following information (see
instructions
for more detail):
1. Complete description of the proposal.
2. Location of the project, adjacent facilities, and waterways on a USGS topographic map. Including the location and
latitude / longitude for all UIS wastewater systems on this map. Also, provide a tax lot map for this project.
3. Schedule for development, including future expansion plan if applicable.
4. Schematic diagrams of waste streams and treatment / disposal facilities. Include the source and quantity of
drainging water and water used for processing or manufacturing.
5. Wastewater characterization.
6. Plans for disposal of solid waste and sledges.
7. Site evaluation report prepared as outlined by OAR 340-071-0150 (on-site sewage disposal systems only).
8. Groundwater information for all areas where wastewater or sludge will be stored or disposed.
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9. Evaluation of groundwater and surface water impacts and the steps that will be taken to prevent impacts from
occurring
10. Operation and maintenance plan that specifies the normal operation parameters of the system.
G. Land Use Compatibility Statement
Attach a complete Land Use Compatibility Statement (LUCS) signed by the local land use authority. The application
will not be processed without evidence that the proposal is approved by the local land use authority and meets statewide
planning goals.
H. Underground Injection Control (UIC) Registration
Federal and state regulations require that all UIC systems be registered with DEQ. By completing this application, your
wastewater UIC systems (UIC) will be registered with the DEQ and you will be sent a UIC registration conformation
letter to be maintained at the facility. You will be informed by DEQ of any additional UIC regulations that are
applicable to your UIC system once this application has been reviewed.
I. Signature Of Legally Authorized Representative
I hereby certify that the information contained in the application is true and correct to the best of my knowledge and
belief. In addition, I agree to pay all permit fees required by Oregon Administrative rules 340-045 and/or 340-071. This
includes a new application fee to obtain the permit and a compliance determination fee invoiced annually by DEQ to
maintain the permit.
___________________________________________________
___________________________________________
Name of Legally Authorized Representative (Type or Print)
Title
___________________________________________________
___________________________________________
Signature of Legally Authorized Representative
Date
DEQ Use Only
Regional WQ Permit Coordinator Route copy of application and Preliminary Engineering Report / Facility Plan to HQ
UIC Coordinator.
Date Sent to HQ and Initials: ____________________
Date Received by HQ and Initials: _____________________
EPA Well Type
5A5 Electric Power Generator
5R21 Aquifer Recharge
5W20 Industrial Process Water
5X15 In Situ Fossil (fuel recover)
5A6 Geothermal Heat (open loop)
5W9 Untreated Sewage
5W31 Septic System (well disposal)
5X16 Spent Brine Return Flow
5A7 Closed Loop Heat Pump Return
5W10 Cesspool
5W32 Septic System (drain field)
5X25 Experimental Technology
5A19 Cooling Water Return
5W11 Septic System (general)
5X13 Mine Tailing Backfill
5X26 Aquifer Remediation
5G30 Special Drainage Water
5W12 Water Treatment Plant Effluent
5X14 Solution Mining
5X27 Other Wells
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Application Instructions For New WPCF Individual Permit
Oregon Department of Environmental Quality
Please answer all questions and submit with the required application fees.
An incomplete application or application with incorrect fees 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 this entity. This is the person, business, public
organization, or other entity that controls the facility described in this application and will be responsible for
complying with the conditions of the permit. This must be the legal Oregon name (i.e., Acme Products, Inc.) or the
legal representative of the company if it operates under an assumed business name (i.e. John Smith, dba Acme
Products). The name must be a legal active name registered with the Oregon Department of Commerce, Corporation
Division (503-378-4752), unless otherwise exempted by their regulations
2. Indicate if the applicant is the owner of the facility.
3. Provide the legal status of the applicant. Indicate "public" for a facility solely owned by local government.
4. Enter the common name of the facility or operation if different than the legal name of the applicant.
5. Enter the Standard Industrial Classification (SIC) four-digit code or North American Industry Classification System
five or six-digit code (NAICS) for the facility. These codes are used to describe the primary activity at the facility and
may be found on fire marshal reports, insurance papers, or tax forms. The NAICS codes replaced the SIC system in
1997, however, it is usually easy to convert between the two systems so either code is acceptable. SIC or NAICS
information is also available from the U.S. Census Bureau at 1-888-756-2427 or at http://www.naics.com/search.htm.
B. Facility Location
1. Enter the physical location of the facility (street address, not mailing address), including city, state, zip code, and
county.
2. Enter the latitude and longitude of the approximate center of the facility or site in degrees/minutes/seconds. Latitude
and longitude can be obtained from DEQ’s location finder web site at
https://www.oregon.gov/deq/wq/wqpermits/Pages/Tools-and-Data.aspx
or from United States Geological Survey
(USGS) quadrangle topographic maps by calling toll-free at 1-888-ASK-USGS (1-888-275-8747). For obtaining
latitude and longitude from USGS maps, instructions may be obtained from DEQ’s web site at
http://www.oregon.gov/deq/FilterDocs/latlonginstr.pdf.
3. Enter the Township, Range, Section, and Tax Lot numbers for the regulated site.
C. Facility Contacts
1. Enter the name, telephone number, and mailing address of 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.
2. Enter the name, telephone number and mailing address of 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 (e.g., the treatment plant operator), and may be contacted if there are specific questions about
this application.
3. Enter invoicing information for billing purposes if different from the Responsible Official (e.g., "Invoice To:
Business Office - Accounts Payable").
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Application Instructions For New WPCF Individual Permit
Oregon Department of Environmental Quality
D. General Information
1. Briefly describe the proposed facility, type of wastewater (industrial, sewage or both), and primary method of
wastewater treatment and disposal. For example, "2 MGD domestic sewage treatment plant consisting of non-
discharging, evaporative lagoons" or "Seasonal jelly processing facility with land irrigation of process wastewater."
2. Indicate if a sanitary sewer system is available to receive this wastewater. If "yes," explain why this discharge is not
being connected to sanitary sewer.
3. Indicate if the facility includes a graywater reuse disposal system.
4. Indicate if an Underground Injection Control (UIC) system will be used or is currently used to dispose of wastewater
for the proposed facility described in D.1. Wastewater includes wash waster, process wastewater, and/or sewage. The
following wastewater disposal systems are considered UICs:
Multi-family residential onsite
Dry wells or sumps
Non-residential onsite sewage
sewage systems regardless of
Infiltration trenches
system with a design flow of
size.
French drains
2,5000 gallons per day or
Any onsite sewage system,
Industrial wasterwater drain hose
designed to serve 20 or more
regardless of size, that receives
people a day (excluding single-
Cesspools / sewage drain holes
industrial wastewater
family residential systems)
5. Indicate if there is any other wash water or wastewater at the regulated site that will be or is being discharged to a
UIC system not included in the proposed facility description found in D.1. If "yes," also provide the information
required in Section F, Preliminary Engineering Report/Facility Plan for each UIC.
6. Indicate if a UIC system other than the one described in this application will be used or is currently used to drain
storm water. If "yes," complete the UIC Registration Form: Storm Water Drainage Systems enclosed with this
application. The following storm drainage systems are considered UICs:
Any UIC wastewater system
Dry wells or sumps
French drains
also used form storm drain
Infiltration trenches
Storm drain holes
E. Other DEQ or Public Agency Permits
In order for DEQ to coordinate with other DEQ divisions and public agencies, list all permits issued to or applied for this
project.
F. Preliminary Engineering Report / Facility Plan
Two copies of a Preliminary Engineering Report or Facility Plan Report must accompany this application and contain the
following minimum information:
[Note: When constructing community sewage treatment facilities, also refer to DEQ's Guidelines for Planning Community
Wastewater Projects (January 1998) for assistance on developing a facility plan.]
1. A description that includes all aspects of the facility, including services to be provided and activities to be conducted.
2. A USGS topography map that shows the location and scope of the project, locations of adjacent facilities, waterways,
wetlands, drainage ways, residential areas, industrial facilities, and commercial areas, including the location and
latitude/longitude for all UIC wastewater systems. Also provide a tax lot map for the project.
3. The proposed development and construction schedule. Also include future expansion plans or potential plans.
4. Schematic diagrams that include each waste stream, collection facilities, treatment and control facilities, and ultimate
disposal methods for each waste product or wastewater effluent. Include a water balance for each waste stream. If
alternatives for treatment are also being considered, they should be included as well. Also include the source and
quantity of drinking water and water used for processing or manufacturing if different from drinking water supply.
5. A characterization of the quantity and quality of each waste stream.
6. Plans for collection, storage, and disposal of any sludges generated by the treatment process, including a
characterization of volume and quality.
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