"Water Pollution Control Facilities Permit Renewal Application" - Oregon

Water Pollution Control Facilities Permit Renewal Application 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
OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY
Application #
Date Received:
RENEWAL APPLICATION
WATER POLLUTION CONTROL FACILITIES PERMIT
Total Amount Received:
File#
(WPCF-R)
Onsite Surcharge:
Mail ID #2/#9
Check #
LLID/RM:
Deposit #
ACD Fee Paid:
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IND
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UIC
DOC Conf:
Notes:
Notes:
A. REFERENCE INFORMATION
1. Legal Name:
2. Common Name:
3. Permit #:
DEQ Site ID#:
Permit Expiration Date:
Physical Facility Street Address:
4.
City, State, Zip Code:
County:
5. Township:
Range:
Section:
Tax Lot #
Responsible Official:
Mailing Address:
City, State, Zip Code:
6.
Telephone:
Email Address:
Facility Contact:
Mailing Address:
City, State, Zip Code:
7.
Telephone:
Email Address:
Invoice Contact:
Mailing Address:
City, State, Zip Code:
8.
Telephone:
Email Address:
B. REQUIRED INFORMATION
Briefly describe the permitted facility, type of wastewater, and primary method of wastewater treatment and disposal:
1.
Have the treatment or disposal methods employed, as indicated in previous applications, been altered in any way since
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the last application was submitted?
YES
NO
If "YES", explain:
2.
Has the quantity or quality of wastes discharged, as indicated in previous applications, been significantly changed in any
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way since the last application was submitted?
YES
NO
If "YES", explain:
3.
4. If there any changes anticipated in the near future that would affect waste quantity or quality, attach an explanation or proposal.
Review each condition of your current permit and attach a brief report that indicates your progress in meeting the requirements,
5.
limitations, and compliance schedules of the permit.
6. If the permitted facility or operation is a domestic wastewater treatment plant, attach a copy of your Biosolids Management Plan.
C. 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. This includes a renewal application fee to renew 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
DEQ USE ONLY
OREGON DEPARTMENT OF ENVIRONMENTAL QUALITY
Application #
Date Received:
RENEWAL APPLICATION
WATER POLLUTION CONTROL FACILITIES PERMIT
Total Amount Received:
File#
(WPCF-R)
Onsite Surcharge:
Mail ID #2/#9
Check #
LLID/RM:
Deposit #
ACD Fee Paid:
g
f
e
d
c
g
f
e
d
c
g
f
e
d
c
g
f
e
d
c
IND
DOM
OSS
UIC
DOC Conf:
Notes:
Notes:
A. REFERENCE INFORMATION
1. Legal Name:
2. Common Name:
3. Permit #:
DEQ Site ID#:
Permit Expiration Date:
Physical Facility Street Address:
4.
City, State, Zip Code:
County:
5. Township:
Range:
Section:
Tax Lot #
Responsible Official:
Mailing Address:
City, State, Zip Code:
6.
Telephone:
Email Address:
Facility Contact:
Mailing Address:
City, State, Zip Code:
7.
Telephone:
Email Address:
Invoice Contact:
Mailing Address:
City, State, Zip Code:
8.
Telephone:
Email Address:
B. REQUIRED INFORMATION
Briefly describe the permitted facility, type of wastewater, and primary method of wastewater treatment and disposal:
1.
Have the treatment or disposal methods employed, as indicated in previous applications, been altered in any way since
g
f
e
d
c
g
f
e
d
c
the last application was submitted?
YES
NO
If "YES", explain:
2.
Has the quantity or quality of wastes discharged, as indicated in previous applications, been significantly changed in any
g
f
e
d
c
g
f
e
d
c
way since the last application was submitted?
YES
NO
If "YES", explain:
3.
4. If there any changes anticipated in the near future that would affect waste quantity or quality, attach an explanation or proposal.
Review each condition of your current permit and attach a brief report that indicates your progress in meeting the requirements,
5.
limitations, and compliance schedules of the permit.
6. If the permitted facility or operation is a domestic wastewater treatment plant, attach a copy of your Biosolids Management Plan.
C. 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. This includes a renewal application fee to renew 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
APPLICATION INSTRUCTIONS FOR RENEWAL NPDES INDIVIDUAL PERMIT
Please answer all questions.
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
Enter the legal name of the applicant. This must be the legal Oregon name (i.e., Acme Products, Inc.) or the legal
1.
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. The permit will be issued to the
legal name of the applicant.
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 available by contacting a DEQ regional office listed below or at:
http://www.deq.state.or.us/wq/wqpermit/docs/forms/pmttfrappl.pdf
2.
Enter the common name of the facility or operation if different than the legal name.
Enter the permit number, DEQ site identification number (also known as the facility number or file number; this
3.
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 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.
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.
Enter invoicing information for billing purposes if different from the Responsible Official (e.g., "Invoice To: Business
Office -Accounts Payable").
B.
REQUIRED INFORMATION
1.
Briefly describe the permitted 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.”
2-6. Complete the remaining questions as indicated. Attach any additional pages of explanation, including any diagrams
or maps that are needed to update the Department.
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. See the
1.
table below for more information.
DEFINITION OF LEGALLY AUTHORIZED REPRESENTATIVE:
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 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 offical
● Limited Liability Company - Member [articles of organization]
● 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
dateof your current permit.
DEQ Northwest Region
DEQ Western Region
DEQ Eastern Region
2020 SW 4th Avenue, Suite 400
750 Front Street NE, Suite 120
700 SE Emigrant Avenue, Suite 330
Portland, OR 97201-4987
Salem, OR 97301-1039
Pendleton, OR 97801
503-229-5263 or 1-800-452-4011
503-378-8240 or 1-800-349-7677
541-276-4063 or 1-800-452-4011
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