ࡱ> '` .bjbj _...8f|< *Pz(A [L($| h ^"A}J 555p555| E .G` 0 B  B $B H5X $&T [$T& [ Form DEPLW0105-B2003Revised December 23, 2008fb88 Department of Environmental ProtectionGeneral Application forWaste Discharge License (WDL)/fb88 Pollutant Discharge Elimination System (MEPDES) PermitRegulatory requirements for the preparation and filing of applications may be found in Chapters 2, 521 and 522 of the Departments rules. GENERAL INSTRUCTIONS This general form is to be used to make application for the discharge of pollutants to the surface waters of the State, from all sources except from privately owned discharges subject to the Over Board Discharge Program requirements and for a combination Concentrated Animal Feeding Operation/Livestock operating Permit. Applicants are responsible for publishing public notice of their application at the time it is filed with the Department. See pages 7 and 8. For a proposed new discharge of wastewater of more than 25,000 gallons per day or a project involving licenses from more than two bureaus in DEP, and applicant must conduct a public informational meeting before submitting an application. See page 7. In some circumstances an applicant must have a pre-application or pre-submission meeting with the Department prior to filing of an application. See page 9. At the time an application is filed with the Department, a copy must be provided to the municipal office and notice provided to all abutters by certified mail. See page 7. Application fees must be paid at the time an application for a new discharge or permit is filed. Contact the Department for additional information and calculation of the fee amount. For existing discharges, fees are charged on an annual basis and application fees are not required with an application for permit renewal. Attach additional sheets as necessary in answering specific questions. Be sure to number each sheet to identify the question to which it pertains. Failure to fully complete all required forms or to pay necessary application fees will result in the application being returned. After completing the application, submit 2 copies to: fb88 Department of Environmental Protection Bureau of Land and Water Quality Division of Water Quality Management 17 State House Station Augusta, ME 04333-0017 Please read the entire application form before furnishing any information. If you need any assistance in filing out the form or required attachments, please contact the Department at the above address or by calling (207) 287-3901. Assigned Project Manager:Date: FORMTEXT         FORMCHECKBOX New discharge FORMCHECKBOX Renewal FORMCHECKBOX Increased discharge FORMCHECKBOX Transfer of owner FORMCHECKBOX Modification FORMCHECKBOX Other:If assigned:MEPDES#ME FORMTEXT      WDL#W FORMTEXT       FACILITY AND APPLICANT INFORMATION 1.Facility Information (911Address):  FORMTEXT      Facility Name: FORMTEXT      Receiving Water(s) FORMTEXT      Town: FORMTEXT      State:  FORMTEXT      Zip: FORMTEXT      Global Positioning System (GPS) reference data if available FORMTEXT      Facility Type: FORMCHECKBOX Federal FORMCHECKBOX State FORMCHECKBOX Other Public  FORMCHECKBOX Private FORMCHECKBOX Other2.Applicant Information:Name: FORMTEXT      Telephone: FORMTEXT      Address: FORMTEXT      E-mail: FORMTEXT      Town: FORMTEXT      State: FORMTEXT      Zip FORMTEXT      3.Owner information (if different from Applicant):Name: FORMTEXT      Telephone: FORMTEXT      Address: FORMTEXT      E-mail: FORMTEXT      Town: FORMTEXT      State: FORMTEXT      4.Operator information (if different from Applicant/Owner):Name: FORMTEXT      Telephone: FORMTEXT      Address: FORMTEXT      E-mail: FORMTEXT      Town: FORMTEXT      State: FORMTEXT      NOTE: If a wastewater treatment facility is operated under a contract with a third party, the contract for services must be reviewed and approved by the Department.5.Cognizant Official (Person to whom correspondence regarding this application should be sent:Name: FORMTEXT      Telephone: FORMTEXT      Address: FORMTEXT      E-mail: FORMTEXT      Town: FORMTEXT      State: FORMTEXT      6.Person in responsible charge of the treatment facility operations:Name: FORMTEXT      Telephone: FORMTEXT      Operator's license #  FORMTEXT      Grade:  FORMTEXT      Professional Engineer? FORMCHECKBOX Yes FORMCHECKBOX No7.Briefly describe nature of business and activities requiring WDL/MEPDES Permit: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        ELECTRONICALLY SIGNED DECISIONS Electronically signed decision options. To expedite processing of applications and reduce paper usage, all final decisions on an application will be electronically signed by the Commissioner (or his/her designee) and will be sent to the respective e-mail addresses provided for the Applicant and the Cognizant Official listed on this application, unless the opt out signature block is signed below. I hereby decline to receive an electronically signed decision on the WDL/MEPDES permit via e-mail and choose to receive manually signed (hand written) decision via regular (U.S. Postal) mail. Sign to DECLINE only (Applicant):Date: FORMTEXT       SUPPORTING MATERIALS AND REQUIRED ATTACHMENTS 9.For new and transfer applications only from privately-owned facilities, include: FORMCHECKBOX A Certificate of Good Standing issued by the Maine Secretary of State. FORMCHECKBOX A Proof of Title, Right or Interest (TRI) in the property on which the treatment system and outfall pipes and structures are or will be located. See Chapter 2 of the Departments rules for TRI criteria.10.For transfer applications only, answer the following then skip to the Certification on page 6.A.Name of current/former owner: FORMTEXT      B.Describe any planned changes in the current discharge: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      C.Provide a statement describing the technical and financial capacity to comply with the current permit conditions and applicable laws and rules.11.Unless submitted previously and there have been no changes, provide a topographic map (or other map if a topographic map is unavailable) extending one mile beyond the property boundaries of the source, depicting the facility and each of its intake and discharge structures (showing latitude and longitude to the nearest 15 seconds), each of its hazardous waste treatment, storage, or disposal facilities; each well where fluids from the facility are injected underground; and those wells, springs, other surface water bodies, and drinking water wells listed in public records or otherwise known to the applicant in the map area.11.If modification of an existing permit is being requested, attach a statement describing the nature of the modification and the reasons or circumstances necessitating the change. Include any relevant modified process flow schematics available.  13.Attachments for specific activities and circumstances. For each specific question, check Yes or No to indicate if the statement is applicable to a discharge or activity described in this application. Where Yes is checked, attach the applicable form. Specific QuestionYesNoApplicable FormA.Is this facility a public owned treatment works treating sanitary wastewaters? FORMCHECKBOX  FORMCHECKBOX DEP Form: Publicly Owned Treatment Facilities (DEPLW0106)B.Does this application seek authorization to introduce septage into treatment works? FORMCHECKBOX  FORMCHECKBOX DEP Form: Disposal of Septage and Holding Tank Wastes in Wastewater Treatment Facility (DEPLW0507-A2004)C.Is this application for a subsurface wastewater disposal system? FORMCHECKBOX  FORMCHECKBOX DEP Form: Application for Subsurface Wastewater Disposal System. (DEPLW0313-B2005)D.Is this application for a land surface (including spray irrigation) wastewater disposal system? FORMCHECKBOX  FORMCHECKBOX DEP Form: Application for Surface Wastewater Disposal System (DEPLW0450-B2005)E.Is this a food processing facility or POTW that treats food processing wastewaters? FORMCHECKBOX  FORMCHECKBOX DEP Form: Food Processing Facilities (DEPLW1999-19)F.Is this an Existing discharge of industrial process wastewater: FORMCHECKBOX  FORMCHECKBOX EPA Form: 2CG.Is this to be a new discharge of industrial process wastewater? FORMCHECKBOX  FORMCHECKBOX EPA Form 2DH.Is this a discharge of non-contact cooling water? FORMCHECKBOX  FORMCHECKBOX EPA Form 2EI.Is this discharge of storm water associated with an industrial activity? FORMCHECKBOX  FORMCHECKBOX EPA Form 2FJ.Is this a discharge of non-process wastewater? FORMCHECKBOX  FORMCHECKBOX EPA Form 2EK.Is this application for an Atlantic Salmon net pen facility? FORMCHECKBOX  FORMCHECKBOX EPA DEP Form: Supplemental Information for Atlantic Salmon Aquaculture Net Pen (for Individual Permit) (DEPLW0956)L.Is this a fish hatchery or rearing facility? FORMCHECKBOX  FORMCHECKBOX DEP Form: Fish Rearing Facilities (DEPLW1999-18)M.Is this an application for the use of aquatic pesticides? FORMCHECKBOX  FORMCHECKBOX DEP Form: Aquatic Pesticides (DEPLW-141-A99)N.Does this application involve a new or modified outfall structure? FORMCHECKBOX  FORMCHECKBOX DEP Form: Outfall Information (DEPLW1999-17)O.Is this application for a waste snow dump? FORMCHECKBOX  FORMCHECKBOX DEP Form: Supplemental Information for snow Dumps (DEPLW0249)  OUTFALL AND TREATMENT INFORMATION Use attachments as necessary to provide details for each discharge point and treatment system. 14.Outfall Number/NameDescriptionVolume DischargedReceiving Water FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       If any of the above-listed discharges (other than CSOs) are intermittent or seasonal, please describe the nature, circumstances and duration of each. 15.Briefly describe current treatment facilities or methods for each discharge. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       16.If this is a renewal application, please describe all significant modifications to the treatment facilities (and collection system if applicable) since the last permit application was filed. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       17.Are new or expanded treatment facilities or outfall structures being proposed? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please include a construction schedule. Plans and specifications must be submitted to the Department for review and approval prior to construction of the facilities.18.If this application is for a new or increased discharge, include a statement that:A.Describes in detail the nature of and reason for the requested increase in pollutant loading to the receiving water; FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      B.If the Department determines that the discharge will diminish the remaining assimilative capacity of the receiving water, demonstrates that alternative methods to reduce or eliminate the increased discharge are not feasible. Include engineering and economic analyses that consider alternative methods of production, process controls, wastewater minimization methods, improved wastewater treatment methods and alternate disposal sites; and  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      C.If the Department determines that the discharge will diminish the remaining assimilative capacity of the receiving water, demonstrates that the increased pollutant load will result in important social and economic benefits to the State. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        CERTIFICATION I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Additionally, by signing below, I certify that Notice of this application has been made by publication in  FORMTEXT {"Newspaper name"} newspaper circulated in the area where the project site is located on or about FORMTEXT {"date"} (a copy of advertising form is included in this application; (2) notice has been sent by certified mail or Certificate of mailing to owners of land abutting the discharge site (a copy of the list of abutters is included in this application); and (3) notice and a copy of this application have been provided to the clerk of the municipality(ies) where the discharge is located. (4) Further, if this is a new discharge over 25,000 gallons per day, a public meeting attended by approximately  FORMTEXT {"number"} members of the public was held on  FORMTEXT {"date"}. The forgoing steps have been taken in accordance with the instructions attached to this application and the provisions of Chapters 2 and 522 of the Department s rules. By: Signature:Date: FORMTEXT      Printed Name: FORMTEXT      Telephone: FORMTEXT      Title: FORMTEXT       Assisting parties. If the applicant has been assisted in preparing this application, the person assisting must sign below. Signature:Date: FORMTEXT      Printed Name: FORMTEXT      Telephone: FORMTEXT      Affiliation: FORMTEXT      Address: FORMTEXT      Town: FORMTEXT      State: FORMTEXT      Zip FORMTEXT      Professional Certification: FORMTEXT      See following pages for requirements on public notice, public meeting, pre-applications meetings and pre-submission meetings.  Instructions for providing notices of the application. For all applications, the first 3 items must be completed. If the application is for a new discharge, you must also complete item 4. 1. Publication of Public Notice. Applicants for waste discharge permits are required to publish a public notice that the application is being filed with the Department of Environmental Protection. The notice must be published within 30 days prior to the application being sent to the weekly newspaper having general circulation in the area where the discharge will occur. If the public notice is not published at the proper time or if the application is returned because it is incomplete, you may be asked to have the notice published a second time. Using the form on the next page, fill in the blanks with the appropriate information. Strike out all of the items (CSO, multiple discharge sources, etc.) in the second paragraph that do not apply to your discharge. The form may then be sent to the newspaper that is to publish the notice. Additionally, include a copy of the form with the application filed with the Department. Notice to Abutters. Applicants are also required to send a copy of the public notice by certified mail or Certificate of Mailing to all abutting property owners within 30 days prior to the application being filed with the Department. For the purposes of public notice of this application, an abutter is any person who owns property that is both (1) adjoining and (2) within 1 mile of the delineated project boundary, including owners of property directly across a public or private right of way. Additionally, include a copy of the form with the application filed with the Department. Notice to Municipal Office. 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Public Meeting. Where the application is for a new discharge of greater that 25,000 gallons per day, you must hold a public meeting in accordance with Chapter 2, Section 8, of the Departments rules. Notice of the meeting must be sent to abutters and the clerk of the municipality(ies) where the discharge is located at least 10 days prior to the meeting. Notice of the meeting must be published in the same newspaper used to publish the notice of filing. After all required notices have been made; sign the statement on the Certification page of the application.  NOTICE OF INTENT TO FILE MAINE WASTE DISCHARGE LICENSE/MAINE POLLUTANT DISCHARGE ELIMINATION SYSTEM PERMIT APPLICATION Please take note that, pursuant to 38 MRSA, Sections 413 and 414-A,  FORMTEXT {"name"}of  FORMTEXT {"address"} intends to file a wastewater discharge permit application with the Department of Environmental Protection (DEP). The application is for the discharge of  FORMTEXT {"volume"} of  FORMTEXT {"describe waste source"} to the  FORMTEXT {"receiving water"} in  FORMTEXT {"municipality"}, fb88. Include as applicable: CSO: Included in this application is the discharge from  FORMTEXT {"number of points"} Combined Sewer Overflows to  FORMTEXT {"list all receiving water"}. Multiple industrial point sources: The application includes  FORMTEXT {"all additional/secondary point source"}s associated with the primary activity described above. Antidegradation: The application proposes a new or increased discharge that may lower existing receiving water quality within its legal classification, and the application contains a statement regarding important social and economic benefits resulting from the activity causing the discharge, pursuant to 38 MRSA, Section 464. Mixing Zone: The application includes a request for establishment of mixing zone in the  FORMTEXT {"receiving water"}, inside of which classifications standards and uses not need to be met, pursuant to 38 MRSA, Section 451. The application will be filed on or about  FORMTEXT {"date"} and will be available for public inspection at DEPs Augusta office during normal business hours. A copy may also be seen at the municipal offices in  FORMTEXT {"municipality"}. A request for public hearing or request that the Board of Environmental Protection assume jurisdiction over this application must be received by the DEP, in writing, no later than 20 days after the application is found acceptable for processing, or 30 days from the date of this notice, whichever is longer. Requests shall state the nature of the issue(s) to be raised. Unless otherwise provided by law, a hearing is discretionary and may be held if the Commissioner or the Board finds significant public interest or there is conflicting technical information. During the time specified above, persons wishing to receive copies of draft permits and supporting documents, when available, may request them from DEP. Persons receiving a draft permit shall have 30 days in which to submit comments or to request a public hearing on the draft. Public comment will be accepted until a final administrative action is taken to approve, approve with conditions or deny this application. Written public comments or requests for information may be made to the Division of Water Quality Management, Department of Environmental Protection, State House Station #17, Augusta, ME 04333-0017. Telephone: (207) 287-3901. Pre-application and pre-submission meetings Pre-application meetings. Pre-application meetings between the applicant and the Department are an opportunity for the applicant to determine the statutory and regulatory requirements that apply to a specific project and to identify a Project Manager for the application. The purpose of these meetings is to identify issues, processing times, fees and the types of information and documentation necessary for the Department to properly assess the project. The applicant shall consult the appropriate bureau Permit Assistance Coordinator to determine what information the applicant must provide before or during a pre-application meeting. Any applicant may request a pre-application meeting. The Department shall make a date available for the meeting as expeditiously as possible, but no later than 30 days from receipt of a written request receipt of all information required for a pre-application meeting by the bureau. The Department shall prepare a written summary of all pre-application meetings. For waste discharge permits, pre-application meetings are required prior to submission to or acceptance by the Department of an application for the following: New wastewater discharge license for a discharge greater than 25,000 gallons per day (38 M.R.S.A. Sections 413, et seq.); Projects requiring new or amended licenses involving more than two bureaus. Pre-submission meetings. Pre-submission meetings between the applicant and the Department occur after the applicant has finished preparing the application for submission. These meetings are an opportunity to review the assembled application to ensure that the necessary information has been included prior to filing the application with the Department. An applicant may request a pre-submission meeting by contacting the Project Manager, or the Permit Assistance Coordinator for the bureau if no Project Manager has been identified. The Department shall make a date available for the meeting as expeditiously as possible, but no later than 20 days from receipt of a written request. For waste discharge permits, a pre-submission meeting is required prior to submission to or acceptance by the Department of an application for the following: Any application for which a pre-application meeting was held; or Any application that has been previously rejected by the Department (see Chapter 2, Section 7-B of the Departments rules). Waivers. The requirement of pre-application or pre-submission meeting may be waived by written notice from the Department and agreement by the applicant. The Department will agree to waive a pre-application or pre-submission meeting if the Department is satisfied that such a meeting would be of no value in achieving the purposes noted above. Note: The waiver of a pre-application or pre-submission meeting does not waive the public informational meeting required for new discharges of more that 25,000 gallons per day.     fb88 Department of Environmental Protection General Application for WDL/MEPDES Permit Page  PAGE 6 of  NUMPAGES 9   ̌͌quuuuh h^gdJ $ ha$gdo hgdohkdy$$Ifl\(( t0644 layto h$Ifgd ()*459:DEF_`histuьܫܙ܇~rjhcCJaJjhcCJUaJho6CJaJ#jh%hvCJUaJ#j3h%hvCJUaJ#jh%hvCJUaJh%CJaJmHnHu#jh%hvCJUaJh%CJaJjh%CJUaJhoCJaJhWSCJaJ"'(EFPQRnor1hv̏͏IJ̩ė̏}uiaO#jhe|hvCJUaJhe|CJaJjhe|CJUaJhJCJaJhJ6CJaJh86CJaJh8CJaJ#jhchvCJUaJho6CJaJ#j hchvCJUaJhcCJaJhoCJaJhcCJaJmHnHujhcCJUaJ#jihchvCJUaJqrghMNFGz{/0 :; h^gdjm) hgdJ h^gd8 h^gdJ hgdo͏ΏLMxy&'123CDKd|Zbqyٞ°ʣ‘ʣމހxxxoxfxox^hX?CJaJhjm)5CJaJhjm)>*CJaJhjm)CJaJhJ5CJaJh4CJaJ#jhchvCJUaJhcCJaJmHnHu#j#hchvCJUaJhcCJaJjhcCJUaJh8CJaJhJCJaJhe|CJaJmHnHujhe|CJUaJ$;78֞מޡ$a$gdM hgdX? h^gdX? hgdjm) h^gdjm) '()*+,-.öìöì hMhfah0JmHnHujhfa0JUjhMhfa0JUhMhfa0Jhfah`jh`UhX?hX?CJaJhX?5CJaJhX?CJaJhjm)CJaJ +,-. 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