"Application for Water Pollution Control Facilities General Permits 1400 a & B" - Oregon

Application for Water Pollution Control Facilities General Permits 1400 a & B is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

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  • Released on June 7, 2017;
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DEQ USE ONLY
Date received:
Oregon Department of Environmental Quality
APPLICATION
Amount paid:
Water Pollution Control Facilities
Check #:
General Permits 1400 A & B
Application #:
File #:
Notes:
A. REFERENCE INFORMATION
1. Legal Name:
2. SIC Code:
3. Common Name:
4. Permit #:
1400 A or
1400 B
5. Facility Physical Address:
6. Enter Site Location by Latitude and Longitude:
City, State, Zip Code:
Latitude:
Longitude:
County:
7.
Title:
Responsible Official:
Mailing Address:
City, State, Zip Code:
Telephone #:
Email Address:
8.
Title:
Facility Contact:
Mailing Address:
Telephone #:
City, State, Zip Code:
Email Address:
9. Brief description of facility and activities producing wastewater:
B. REQUIRED INFORMATION
Attach additional documentation to describe the following:
1.
A description of the activities conducted at your facility and the processes creating wastewater.
2.
A complete list and the approximate volume of each chemical currently used per year at your facility.
3.
Detailed description of the waste/wastewater treatment process and disposal/reuse system. Include a flow schematic showing all
components and their rated treatment volumes.
4.
Figure showing the proposed land application area indicating locations of any surface water, water wells, and residents.
5.
Figure showing the area’s USDA soil profile (available at: https://websoilsurvey.sc.egov.usda.gov/App/WebSoilSurvey.aspx).
6.
Completed Land Use Compatibility Statement (LUCS). More information on the LUCS is available on line at:
http://www.oregon.gov/deq/Permits/Pages/LUCS.aspx.
Additional information may be needed to process this application which may include: analytical data from waste stream
characterization, agricultural and crop management practices, construction details of any lagoon or wastewater treatment structure.
C. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
I hereby certify that the information contained in this application is true and correct to the best of my knowledge and belief.
In addition, I
agree to pay the annual compliance determination fee invoiced annually by DEQ and all other fees required by Oregon Administrative
A wet signature of a legally authorized representative is required in order to process this application.
Rules, Chapter 340, Division 045.
Please print out this application and sign.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
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last updated: June 7, 2017
DEQ USE ONLY
Date received:
Oregon Department of Environmental Quality
APPLICATION
Amount paid:
Water Pollution Control Facilities
Check #:
General Permits 1400 A & B
Application #:
File #:
Notes:
A. REFERENCE INFORMATION
1. Legal Name:
2. SIC Code:
3. Common Name:
4. Permit #:
1400 A or
1400 B
5. Facility Physical Address:
6. Enter Site Location by Latitude and Longitude:
City, State, Zip Code:
Latitude:
Longitude:
County:
7.
Title:
Responsible Official:
Mailing Address:
City, State, Zip Code:
Telephone #:
Email Address:
8.
Title:
Facility Contact:
Mailing Address:
Telephone #:
City, State, Zip Code:
Email Address:
9. Brief description of facility and activities producing wastewater:
B. REQUIRED INFORMATION
Attach additional documentation to describe the following:
1.
A description of the activities conducted at your facility and the processes creating wastewater.
2.
A complete list and the approximate volume of each chemical currently used per year at your facility.
3.
Detailed description of the waste/wastewater treatment process and disposal/reuse system. Include a flow schematic showing all
components and their rated treatment volumes.
4.
Figure showing the proposed land application area indicating locations of any surface water, water wells, and residents.
5.
Figure showing the area’s USDA soil profile (available at: https://websoilsurvey.sc.egov.usda.gov/App/WebSoilSurvey.aspx).
6.
Completed Land Use Compatibility Statement (LUCS). More information on the LUCS is available on line at:
http://www.oregon.gov/deq/Permits/Pages/LUCS.aspx.
Additional information may be needed to process this application which may include: analytical data from waste stream
characterization, agricultural and crop management practices, construction details of any lagoon or wastewater treatment structure.
C. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
I hereby certify that the information contained in this application is true and correct to the best of my knowledge and belief.
In addition, I
agree to pay the annual compliance determination fee invoiced annually by DEQ and all other fees required by Oregon Administrative
A wet signature of a legally authorized representative is required in order to process this application.
Rules, Chapter 340, Division 045.
Please print out this application and sign.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
- 1 -
last updated: June 7, 2017
WPCF 1400 GENERAL PERMIT 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.
2. Enter your Standard Industrial Classification (SIC) code.
https://www.osha.gov/pls/imis/sicsearch.html
3. Enter the common name of the facility or operation if different than the legal name.
4. Check the box for the appropriate permit number.
5. Enter the physical location of the facility (may not be mailing address), including city, state, zip code, and county.
6. Enter the latitude and longitude for the center of the facility’s tax lot.
7. 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.
8. 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 facility
Foreman), and may be contacted if there are specific questions about this application.
9. Briefly summarize the proposed facility and the general activities performed which will produce wastewater.
B. REQUIRED INFORMATION:
1 - 6. Attach additional documentation as needed to address each item thoroughly.
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:
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].
PERMIT FEES and APPLICATION SUBMITTAL:
Permit application fees are published in OAR 340-045-0075 in Table 70G. Available on line at:
http://arcweb.sos.state.or.us/pages/rules/oars_300/oar_340/_340_tables/340-045-0075_12-10-15.pdf
Please see the regional offices below to determine where to send this application. This application must be submitted with
payment of the first annual permit fee and permit application fee. All fees must be paid before this application can be
processed.
Send this form and fees 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.
800 SE Emigrant Ave., Suite 330
Portland, OR 97232-4100
Salem, OR 97302-1142
Pendleton, OR 97801-2717
503-229-5263 or 1-800-452-4011
503-378-8240 or 1-800-349-7677
541-276-4063 or 1-800-304-3513
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last updated: June 7, 2017
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