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

Renewal 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.

Form Details:

  • Released on December 11, 2017;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
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  • Fill out the form in our online filing application.

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DEQ USE ONLY
Oregon Department of Environmental Quality
Date received:
RENEWAL APPLICATION
Amount paid:
Water Pollution Control Facilities
Check #:
General Permits 1400 A & B
Application #:
Notes:
A. REFERENCE INFORMATION
1. Legal Name:
2. SIC Code:
3. Common Name:
5. Enter Site Location by Latitude and Longitude
4. Permit #:
1400 A or
1400 B
DEQ File#:
Latitude:
Longitude:
Permit Expiration Date:
6. Facility Physical Address:
City, State, Zip Code:
County:
7. Responsible Official:
Title:
Mailing Address:
City, State, Zip Code:
Email Address:
Telephone #:
8. Facility Contact:
Title:
Mailing Address:
City, State, Zip Code:
Email Address:
Telephone #:
B. REQUIRED INFORMATION
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 change in quantity or quality of wastewater since the last application was submitted.
4.
A complete list and the approximate volume of each chemical used per year at your facility.
5.
Any changes anticipated in the near future that would affect wastewater quantity or quality or management of wastewater, or
industrial solids.
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
Rules, Chapter 340, Division 045.
application.
Please print out this application and sign.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
last updated: December 11, 2017
- 1 -
DEQ USE ONLY
Oregon Department of Environmental Quality
Date received:
RENEWAL APPLICATION
Amount paid:
Water Pollution Control Facilities
Check #:
General Permits 1400 A & B
Application #:
Notes:
A. REFERENCE INFORMATION
1. Legal Name:
2. SIC Code:
3. Common Name:
5. Enter Site Location by Latitude and Longitude
4. Permit #:
1400 A or
1400 B
DEQ File#:
Latitude:
Longitude:
Permit Expiration Date:
6. Facility Physical Address:
City, State, Zip Code:
County:
7. Responsible Official:
Title:
Mailing Address:
City, State, Zip Code:
Email Address:
Telephone #:
8. Facility Contact:
Title:
Mailing Address:
City, State, Zip Code:
Email Address:
Telephone #:
B. REQUIRED INFORMATION
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 change in quantity or quality of wastewater since the last application was submitted.
4.
A complete list and the approximate volume of each chemical used per year at your facility.
5.
Any changes anticipated in the near future that would affect wastewater quantity or quality or management of wastewater, or
industrial solids.
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
Rules, Chapter 340, Division 045.
application.
Please print out this application and sign.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
last updated: December 11, 2017
- 1 -
WPCF 1400 GENERAL 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 and the associated fees must also be submitted with this
application. This form is available by contacting a DEQ regional office listed below or at
http://www.oregon.gov/deq/FilterPermitsDocs/pmttfrappl.pdf.
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, fill in the 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.
5. Enter the latitude and longitude for the center of the facility’s tax lot.
6. Enter the physical location of the facility (may not be mailing address), including city, state, zip code, and county.
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.
B. REQUIRED INFORMATION:
1 - 5. Attach additional information 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] .
FEE AND APPLICATION SUBMITTAL:
Permit application fees for general permits 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 at least
60 days prior to the expiration date of your current permit. There is no permit renewal fee but all annual permit fees must be
paid in full. If your application includes a name change, you must include a name change form and appropriate fees before
this application can be processed.
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
4026 Fairview Industrial Dr. SE
700 NE Multnomah St., Suite 600
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
last updated: December 11, 2017
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