"1400b General Permit Annual Report Form" - Oregon

1400b 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 July 17, 2018;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
  • Ready to use and print;
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  • 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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DEQ USE ONLY – Date Received Stamp
1400B General Permit
Annual Report Form
A. REFERENCE INFORMATION
1. Facility Name:
2. WQ File No:
3. Reporting Year:
4. Facility Physical Address:
Facility Contact Name:
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
------
BOD
mg/l
------
5
Lbs/acre/
BOD loading
day
------
DO
mg/l
------
pH
SU
------
TDS
mg/l
------
TKN
mg/l
------
NH
-N
mg/l
------
3
NO
-N
mg/l
------
3
NO
-N
mg/l
------
2
SAR
------
EC
ds/m
------
Chloride
mg/l
------
Sodium
mg/l
------
FOG
mg/l
------
Volume of solids
lbs
Acres for solids
lbs/ac
- 1 -
last updated: July 17, 2018
DEQ USE ONLY – Date Received Stamp
1400B General Permit
Annual Report Form
A. REFERENCE INFORMATION
1. Facility Name:
2. WQ File No:
3. Reporting Year:
4. Facility Physical Address:
Facility Contact Name:
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
------
BOD
mg/l
------
5
Lbs/acre/
BOD loading
day
------
DO
mg/l
------
pH
SU
------
TDS
mg/l
------
TKN
mg/l
------
NH
-N
mg/l
------
3
NO
-N
mg/l
------
3
NO
-N
mg/l
------
2
SAR
------
EC
ds/m
------
Chloride
mg/l
------
Sodium
mg/l
------
FOG
mg/l
------
Volume of solids
lbs
Acres for solids
lbs/ac
- 1 -
last updated: July 17, 2018
8. Sub-surface discharge data:
year total
Parameter
Units
Jan
Feb
Mar
Apr
May
June
Jul
Aug
Sept
Oct
Nov
Dec
Total flow
gallons
------
TSS
mg/l
------
BOD
mg/l
5
------
TKN
mg/l
------
NH
-N
mg/l
3
------
NO
-N
mg/l
3
------
FOG
mg/l
------
pH
SU
Attach additional documentation as needed to describe the following:
9. A description of any significant changes at your facility associated with creating or utilizing process wastewater.
10. A description of any system failure associated with utilizing process wastewater.
11. Figure showing the land application area for process wastewater and solids.
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.
Title
Name of Legally Authorized Representative (Type or Print)
Date
Signature of Legally Authorized Representative
- 2 -
last updated: July 17, 2018
WPCF 1400B GENERAL PERMIT ANNUAL REPORT INSTRUCTIONS
A. REFERENCE 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 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 only. Provide the total number of cases of wine produced during the reporting year.
7. Enter results from your monitoring of the beneficially land applied process wastewater. Provide a monthly
summary and annual total of your data in the appropriate box. Provide your data using the identified units.
Maintain records of any daily data or laboratory reports at your facility so they are available upon request.
Do not submit your daily data or laboratory reports with this report. If more than one sample is collected in
a given month, average the sample results and enter the average in the appropriate location. If you did not
discharge, place “ND” in the appropriate box for your results for the month of no discharge. If you are not
required to collect data for a specific parameter or if you have received written notice from DEQ identifying
specific monitoring reduction for your facility, place “NA” in the appropriate box for your results for the
exempt parameter.
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.
Irrigation rate – the total gallons of wastewater land applied each month divided by the total acres
irrigated with process wastewater.
BOD
– Analytical results for 5 day biochemical oxygen demand of process wastewater
5
BOD loading calculated using the formula in your permit and copied below:
M = C x V x (0.000008345)
A
Where:
M = BOD mass for a given field in pounds per acre per day (lb/ac/day);
C = reported BOD
monitoring result for the applicable calendar month in milligrams per liter
5
(mg/L);
V = average gallons per day applied to a given field. This is the monthly average of the daily
volume of effluent discharged to the field;
A = Area of the field irrigated in acres;
0.000008345 = units conversion factor for converting the product of mg/L and gallons to pounds
DO – dissolved oxygen measurement of process wastewater in mg/l
pH – the pH of the process wastewater
TDS – the analytical results for total dissolved solids in the process wastewater
TKN – the analytical results for total Kjeldahl nitrogen in the process wastewater
NH
-N – the analytical results for ammonia nitrogen in the process wastewater
3
NO
-N – the analytical results for nitrate nitrogen in the process wastewater
3
NO
-N – the analytical results for nitrite nitrogen in the process wastewater
2
SAR – the analytical results for sodium absorption ratio of the process wastewater
EC – the electrical conductivity measurement of the process wastewater
Chloride – the analytical results for chloride in process wastewater
Sodium – the analytical results for sodium in process wastewater
FOG - the analytical results for fats, oil, and grease in 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.
- 3 -
last updated: July 17, 2018
WPCF 1400B GENERAL PERMIT ANNUAL REPORT INSTRUCTIONS
8. Enter results from your monitoring of the wastewater discharge for subsurface disposal. Provide a monthly
summary and annual total of your data in the appropriate box. Provide your data using the identified units.
Maintain records of any daily data or laboratory reports at your facility so they are available upon request.
Do not submit your daily data or laboratory reports with this report. If you did not discharge, place “ND” in
the appropriate box for your results for the month of no discharge. If you are not required to collect data for
a specific parameter or if you have received written notice from DEQ identifying specific monitoring
reduction for your facility, place “NA” in the appropriate box for your results for the exempt parameter.
Total flow – the total gallons of process wastewater discharged to subsurface disposal
TSS – the analytical results for total suspended solids in the process wastewater
BOD
– Analytical results for 5 day biochemical oxygen demand of process wastewater
5
TKN – the analytical results for total Kjeldahl nitrogen in the process wastewater
NH
-N – the analytical results for ammonia nitrogen in the process wastewater
3
NO
-N – the analytical results for nitrate nitrogen in the process wastewater
3
FOG - the analytical results for fats, oil, and grease in process wastewater
pH – the pH of the process wastewater
9. Provide a brief description of changes to your wastewater production and processing during the reporting
year. Attach additional pages as needed.
10. Provide a description of system failures or major maintenance activities that occurred during the reporting
year.
11. 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.
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
- 4 -
last updated: July 17, 2018
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