"1400a General Permit Annual Report Form" - Oregon

1400a General Permit Annual Report Form is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • Released on June 27, 2018;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Oregon Department of Environmental Quality.

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For DEQ Use Only
State of Oregon
Date Received
Department of Environmental Quality
Stamp
700 NE Multnomah St, Suite 600
Portland, Oregon 97232
1400A General Permit
Annual Report Form
A. Applicant Information
1. Facility Name:
2. WQ File No:
3. Reporting Year:
4. Facility Contact Name:
Facility Physical Address:
County:
City:
State:
Zip Code:
Mailing Address:
City:
State:
Zip Code:
Email Address:
Telephone #:
5. Responsible Official:
Title:
Mailing Address:
City:
State:
Zip Code:
Email Address:
Telephone #:
B. Required Information
. Wineries - Cases of wine produced during the reporting year:
6
7. Land application data:
Parameter
Units
April
May
June
July
Aug
Sept
Oct
Nov
year total
Days discharging
days
Total flow
gallons
Irrigated acres
acres
------
Irrigation Rate
gal/ac
------
Volume of solids
lbs
Acres for solids
acres
Attach additional documentation to describe the following:
8. A description of any significant changes at your facility associated with creating or utilizing process wastewater.
9. A description of any system failure associated with utilizing process wastewater.
10. Figure showing the land application area for process wastewater and solids.
last updated: June 27, 2018
1
For DEQ Use Only
State of Oregon
Date Received
Department of Environmental Quality
Stamp
700 NE Multnomah St, Suite 600
Portland, Oregon 97232
1400A General Permit
Annual Report Form
A. Applicant Information
1. Facility Name:
2. WQ File No:
3. Reporting Year:
4. Facility Contact Name:
Facility Physical Address:
County:
City:
State:
Zip Code:
Mailing Address:
City:
State:
Zip Code:
Email Address:
Telephone #:
5. Responsible Official:
Title:
Mailing Address:
City:
State:
Zip Code:
Email Address:
Telephone #:
B. Required Information
. Wineries - Cases of wine produced during the reporting year:
6
7. Land application data:
Parameter
Units
April
May
June
July
Aug
Sept
Oct
Nov
year total
Days discharging
days
Total flow
gallons
Irrigated acres
acres
------
Irrigation Rate
gal/ac
------
Volume of solids
lbs
Acres for solids
acres
Attach additional documentation to describe the following:
8. A description of any significant changes at your facility associated with creating or utilizing process wastewater.
9. A description of any system failure associated with utilizing process wastewater.
10. Figure showing the land application area for process wastewater and solids.
last updated: June 27, 2018
1
C. Signature of Legally Authorized Representative
I hereby certify that the information contained in this report is complete, true, correct and representative of the wastewater produced
at this facility to the best of my knowledge and belief.
I am aware that there are significant penalties, including the possibility of
fines and imprisonment for submitting false information or failing to notify DEQ once an error is identified.
Name of Legally Authorized Representative (Type or Print)
Title
Signature of Legally Authorized Representative
Date
WPCF 1400A General Permit Annual Report Instructions
A. Applicant Information:
1. Enter the legal name of the facility. This is the name listed on the permit.
2. Enter the file number identified on the permit cover page.
3. Enter the calendar year the data was collected.
4. Enter the facility contact and physical location of the facility (may not necessarily be mailing address),
including city, state, zip code, and county. Include appropriate email address and phone number.
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 annual report.
B. Required Information:
6. For wineries. Provide the total number of cases of wine produced during the reporting year.
7. Provide a monthly summary and annual total of your daily data in the appropriate box. Provide your data
using the identified units. If more than one sample is collected in a given month the results of the sampling
are to be averaged and entered in the appropriate location. (Maintain records of your daily data at your
facility so they are available upon request. Do not submit your daily data with this report.)
Days discharging – number of days material was land applied.
Total flow – the total gallons of process wastewater land applied.
Irrigated acres - total acres of land irrigated with process wastewater each month and yearly total. Total
acreage receiving process water.
Irrigation rate – the total gallons of wastewater land applied each month divided by the total acres
irrigated with process wastewater.
Volume of solids – the total weight of process waste solids beneficially land applied.
Acres for solids – the total acres of land that received process waste solids.
8. Provide a brief description of changes to your wastewater production and processing during the reporting
year. Attach additional pages as needed.
9. Provide a description of system failures or major maintenance activities that occurred during the reporting
year.
10. Provide a figure showing the locations of land application of process wastewater and process solids. This
figure can be drawn on a print out of a downloaded aerial photograph, map, or other graphical and to scale
representation of your facility. Clearly indicate what was land applied and where the material was applied.
last updated: June 27, 2018
2
C. Signature Of Legally Authorized Representative:
The signature of a legally authorized representative must be provided with this annual report. This must be a hand
written signature of a legally authorized representative, not stamped.
Definition of Legally Authorized Representative:
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.
Sole Proprietorship – Owner.
City, County, State, Federal, or other Public Facility – Principal executive officer or ranking elected official.
Limited Liability Company – Member.
Trusts – Acting trustee.
Report Submittal:
Please see the regional offices below to determine where to send this report.
Send this form to the appropriate DEQ regional office:
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 97232-41007
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: June 27, 2018
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