Adem Form 386 – Fill Out and Use This PDF

NOTICE OF INTENT – GENERAL PERMIT NUMBER ALG180000

(ADEM Form 386)

DISCHARGES ASSOCIATED WITH THE SALVAGE AND RECYCLING INDUSTRY CONSISTING OF STORM WATER, NON-CONTACT COOLING WATER, COOLING TOWER AND BOILER BLOWDOWN, DEMINERALIZER WASTEWATER, VEHICLE AND EQUIPMENT WASH WATER, AND STORM WATER FROM PETROLEUM STORAGE AND HANDLING AND EQUIPMENT STORAGE AND MAINTENANCE AREAS

ANSWER ALL QUESTIONS IN APPLICABLE SECTIONS. PLEASE MARK THE “NOT APPLICABLE” BOX IF A SECTION IS NOT APPLICABLE. INCOMPLETE OR WRONG ANSWERS COULD RESULT IN MORE STRINGENT PERMIT REQUIREMENTS. IF SPACE IS INSUFFICIENT TO ADDRESS ANY ITEM BELOW PLEASE CONTINUE ANSWER ON AN ATTACHED SHEET OF PAPER.

FACILITY IDENTIFICATION INFORMATION

A.Name of Facility to be shown on Permit: Name of permittee if different from above:

B.Mailing Address of Facility: – PO Box or Street Route City, State and Zip Code

C.Location (STREET ADDRESS) of Facility:

City, County:

D. Provide the latitudinal and longitudinal coordinates of the facility location. (Front Gate):

Latitude (		) ° (	) ‘ (	) “	N	Longitude (		) ° (	) ‘ (	) “ W

E. Facility Contact Person and Title:

Telephone Number: (		)

F.Standard Industrial Code (SIC) (Names and Codes):

G.Description of industrial activity and land use at the facility:

H.Check the type of discharge at your facility and complete the applicable sections associated with the type checked: [ ] Storm water from automotive recycling and salvage

[ ] Storm water from salvage and recycling of metal scrap (not including automobiles) [ ] Storm water from salvage and recycling of nonmetal scrap

[ ] Noncontact cooling water, boiler blowdown, condensate, and demineralizer wastewater [ ] Storm water from petroleum storage and fueling areas

[ ] Exterior vehicle and equipment wash water

I.Please indicate which, if any, of the discharges in H. are combined.

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J. Has the facility ever been issued an NPDES Permit? Yes [ ] No [ ]

Please provide the permit number and facility name at time of permitting.

Permit Number:

Facility Name:

K. Has the facility been issued an NPDES INDIVIDUAL permit?

Yes [ ] No [ ] NPDES Permit No. AL00

Do you intend to replace your individual permit with this General Permit? Yes [ ] No [ ]

L. Has the facility been issued a State Indirect Discharge (SID) Permit?

Yes [ ] No [ ] SID Permit No. IU

M.Is this Notice of Intent for (circle one):

1.First time issuance of a GENERAL Permit

2.Renewal of GENERAL Permit No. ALG

3.Modification of GENERAL Permit No. ALG

N.Are any of the discharges that you intend to be covered by this permit going to municipal storm sewer? Yes [ ] No [ ]

O.Name of surface water to which the municipal storm sewer discharges:

P. Have you notified the municipality by letter as required by 40 CFR 122.26(a)(4)? Yes [ ] No [ ]

Q.Date facility started or will start operations:

R.What is the size of the site in acres?

S. Do you discharge to any waters of the State that are impaired (303(d) or TMDL)? Yes [ ] No [ ]

(A list of the impaired waters can be found at http://www.adem.state.al.us/programs/water/303d.cnt for 303(d) listed waters and http://www.adem.state.al.us/programs/water/approvedTMDLs.htm for waters subject to a TMDL.)

If yes, do your discharges contain pollutants of concern listed for the impaired water(s)? Yes [ ] No [ ]

If yes, then enhanced BMPs are required. Also, an Individual NPDES Permit may be required, so please contact the Industrial/Municipal Branch of ADEM before proceeding.

DSN001, DSN002, AND DSN003– STORM WATER DISCHARGE INFORMATION NOT APPLICABLE [ ]

A.List latitude and longitude (to seconds) of the point where each discharge exits your property and name of receiving stream:

1.

Latitude (

) ° (

) ‘ (

) “

N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

2.

Latitude (

) ° (

) ‘ (

) “

N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

3.

Latitude (

) ° (

) ‘ (

) “

N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

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B. Has storm water runoff from the facility been analyzed for presence of any known pollutants? Yes [ ] No [	]
If yes, attach the most recent copy of the analysis.

C. Storm water runoff primarily discharges to (check one):

[] 1. Surface water

[] 2. Seeps into the ground

[ ] 3. Municipal storm sewer

D.This permit requires the development and implementation of a Best Management Practice (BMP) Plan. Does the

facility have a BMP Plan? Yes [ ] No [ ]

E. Does the facility have any of the following other control measures to prevent pollution?

1.		Structural control measures (basins, etc.)		Yes	[	]	No	[	]
2.		Treatment of groundwater (retention, aeration)		Yes	[	]	No	[	]
3.		Other. If so, please describe.
F. Known impact on receiving water? Yes [ ] No [				] If yes, to what extent?

G. Were there any past industrial activities on the site that would contribute to storm water contamination?

Yes [ ] No [ ] If yes, please explain:

H. Are any raw materials, finished products, waste products or chemicals exposed to storm water currently or in the last three years? Yes [ ] No [ ]

If yes, please list:

I.Circle the type discharge(s) at your facility and list associated outfall from A. in this section.

Outfall

1.Automotive recycling and salvage

2.Salvage and recycling of metal scrap (not including automobiles)

3.Salvage and recycling of nonmetal scrap

DSN004 – DISCHARGES ASSOCIATED WITH NON-CONTACT COOLING WATER, COOLING TOWER BLOWDOWN, UNCONTAMINATED CONDENSATE, BOILER BLOWDOWN, AND

DEMINERALIZER WASTEWATER

NOT APPLICABLE [ ]

A.List latitude and longitude (to seconds) of the point where each discharge exits your property, name of receiving stream, and type of discharge (non-contact cooling water, cooling tower blowdown, uncontaminated condensate, boiler blowdown, or demineralizer wastewater):

OUTFALLS:

1.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

Type of Discharge

2.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

Type of Discharge

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3. Latitude (		) ° (	) ‘ (	) “ N		Longitude (		) ° (	) ‘ (	) “ W

Receiving Stream

Type of Discharge

4. Latitude (		) ° (	) ‘ (	) “ N		Longitude (		) ° (	) ‘ (	) “ W

Receiving Stream

Type of Discharge

5.

Latitude (

) ° (

) ‘ (

) “ N

Longitude (

) ° (

) ‘ (

) “

W

Receiving Stream

Type of Discharge

B.

If more than one discharge is listed in A. above, can they be sampled separately?

Yes

[

] No [

]

C.

Is there any process water commingled with the cooling and/or blowdown water?

Yes

[

] No

[

]

D.

If answer to C. is yes, can they all be sampled separately? Yes [

]

No [

]

E.

Does surface water intake total 2 million gallons per day or more?

Yes

[

] No

[

]

F.

If answer to E. is yes, is 25% or more of the water intake used for cooling purposes? Yes [

]

No [

]

G.

Is the non-contact cooling water and the cooling tower blowdown discharge less than 100,000 gallons per day (GPD)?

Yes

[ ] No [

]

If no, please include the estimated gallons per day of discharge:

GPD

H.

Do you use biocides, corrosion inhibitors or chemical additives in your cooling or blowdown water? Yes

[ ] No [ ]

If yes, please submit a list of the biocide, corrosion inhibitor or chemical additive with this NOI. The applicant must

also provide:

(1)name and general composition of biocide or chemical,

(2)48-hour median tolerance limit data for organisms representative of the biota of the waterway into which the discharge will ultimately reach. For freshwater, the fathead minnow (Pimephales promelas) and cladoceran (Ceriodaphnia dubia) are the required test organisms. For salt water, the organisms shall be mysid shrimp; and sheepshead minnow or inland silverside.

(3)quantities to be used,

(4)frequencies of use,

(5)maximum proposed discharge concentrations, and

(6)EPA registration of number, if applicable.

*BIOCIDES THAT CONTAIN TRIBUTYL TIN, TRIBUTYL TIN OXIDE, ZINC AND/OR CHROMIUM ARE PROHIBITED BY THIS PERMIT

I.Is your discharge located in the Tennessee or Cahaba River Basin or on the Tallapoosa River between Thurlow Dam

	at Tallassee and the junction of the Coosa River and Tallapoosa River? Yes [		]	No	[	]
J.	Is the boiler blowdown discharge less than 5,000 gallons per day (GPD)? Yes		[	] No	[	]
	If no, please include the estimated gallons per day of discharge						GPD
K.	Is shock chlorination used at the facility? Yes [ ] No [ ]

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L.	Is any source water chlorinated? Yes [		] No	[	] If yes, explain use and list outfall number(s) from A. in this
	section.
M. Is demineralizer wastewater discharged?			Yes [	]	No [	]
N.	Are there any known impacts on the receiving water as a result of the discharge? Yes							[	]	No [ ]
	If yes, to what extent?
O.	Is there a cooling water intake structure (CWIS) associated with this facility?						Yes [ ]	No	[	]
P.	Does the provider of your source water operate a CWIS?					Yes [ ] No [ ]	If your source water is from a WTP that
	also supplies drinking water, then the answer is no.

If the answer to both questions O and P is no, then a Cooling Water Intake Structure Form is not required. If the answer to either or both questions O and P is yes, then a Cooling Water Intake Structure Form must be completed and attached.

COOLING WATER MONITORING OPTIONS

A. Is cooling/blowdown water chlorine free from the time it enters your facility until it is discharged (city water usually contains chlorine)? Yes [ ] No [ ]

IF ANSWER IS YES, DO NOT COMPLETE THIS SECTION

B.If answer is no, which outfall(s) listed above under DSN004 are both chlorinated AND are over 2,500 feet from point of discharge from the facility to the point of entry into the receiving stream?

If you listed any outfalls in question B. you may avoid monitoring for chlorine at that outfall by:

1.Submitting lab data with the Notice of Intent (NOI) that demonstrates that the chlorine concentration at the point the discharge enters the impacted stream is 0.011 mg/l or less, AND

2.Submitting a site drawing showing the distance from the discharge point to the point the effluent enters the impacted stream.

C. For outfalls listed in B. do you intend to exercise the no monitoring chlorine option? Yes [ ] No [ ]

For which outfall(s)?

If your answer is yes to question C. you are certifying by signing this form that the conditions are as stated above in this Section (Cooling Water Monitoring Options) and you are certifying that you understand that you are required to notify ADEM if these conditions change during the term of the permit

DSN006 AND DSN008 – STORM WATER FROM PETROLEUM BULK STORAGE AND FUELING AREAS

NOT APPLICABLE [ ]

A.List latitude and longitude (to seconds) of the point where each discharge exits your property and name of receiving stream:

1.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

2.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

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3.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

4.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

Number

Size

B.List number and size of above ground storage tanks. List number and size of underground storage tanks.

C. Has storm water runoff from the facility been analyzed for presence of any known pollutants? Yes [ ] No [ ] If yes, attach the most recent copy of analysis.

D. Storm water runoff primarily discharges to (check one):

[] 1. Surface water

[] 2. Seeps into ground

[ ] 3. Municipal storm sewer

E.This permit requires the development and implementation of a Best Management Practices (BMP) plan. Does the

facility have a BMP Plan? Yes [ ] No [ ]

F. Does the facility have any of the following other control measures to prevent pollution?

1.

Structural control measures (basins, etc.)

Yes

[

]

No

[

]

2.

Treatment of groundwater (retention, aeration)

Yes

[

]

No

[

]

3.

Other. If so, please describe.

G.

Known impact on receiving water? Yes [ ] No [ ] If yes, to what extent?

H.

Have any leaks, spills or other instances of storm water contamination occurred within the last 3 years?

Yes

[ ] No [ ] If yes, what occurred and how did it happen?

I.

Are any above ground tanks that contain a possible pollutant double-walled?

Yes

[

]

No [

]

J.

Are all above ground tanks that contain a possible pollutant double-walled? Yes

[

]

No

[

]

K.

Are any above ground tanks that contain a possible pollutant diked? Yes

[

]

No

[

]

L.

Are all above ground tanks that contain a possible pollutant diked?

Yes

[

]

No

[

]

M.

Can dikes contain 110% of the contents of the largest tank in the dike?

Yes

[

]

No

[

]

N.

Are the walls and floors of the dikes relatively impermeable to the stored substance?

Yes

[

] No [ ]

O.From which outfalls in A. (this section) is uncontaminated storm water from secondary containment (for above ground storage tanks only) areas discharged?

P. Is treated or untreated water from tank bottoms or water draws discharged on site? Yes [ ] No [ ] If yes, this particular discharge cannot be covered under this permit. Please contact the Industrial branch of ADEM before proceeding.

Q. Were there any past industrial activities on the site that would contribute to storm water contamination?

Yes [ ] No [ ] If yes, please explain:

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R.	Does the facility handle leaded fuels? Yes	[	] No [	]
S.	Does the facility handle aviation fuel, jet fuel, or diesel fuel?				Yes [		]	No	[	]
T.	Is hydrostatic testing of petroleum handling equipment done on site?							Yes	[	] No [ ] If yes, this particular
	discharge cannot be covered under this permit. Please contact the Industrial Section of ADEM before proceeding.
U.	Are any trucks or equipment fueled at this facility? Yes			[	] No [		]	Is your fueling area protected from storm water
	including flowing water? Yes [ ] No [	]	If yes, please explain:

V.Is storm water/wash down water from the fueling/loading area treated (oil/water separator, etc.) prior to discharge? Yes [ ] No [ ]

W. Does the facility comply with 40 CFR Part 112? Yes [ ] No [ ]

Last update of SPCC Plan, if applicable

In accordance with 40 CFR Section 112.5 (b), applicable facilities must complete a review and evaluation of the SPCC Plan at least once every five years. If the provided date indicates the SPCC Plan is not valid, is the SPCC Plan currently being reviewed by a Professional Registered Engineer. Yes [ ] No [ ]

If an SPCC Plan date was not entered, is it because the facility’s petroleum storage capacity is below the volume that

	would require an SPCC Plan? Yes [	] No [	]
X.	Is storm water from fueling areas allowed to mix with storm water from other industrial activities? Yes [ ] No [ ]
Y.	Does any discharge or runoff from the facility reach a public water supply stream segment as defined by ADEM
	Administrative Code R. 335-6-11-.02?	[	] Yes [ ] No

DSN009 – DISCHARGE ASSOCIATED WITH VEHICLE AND EQUIPMENT EXTERIOR WASHING OPERATIONS

NOT APPLICABLE [ ]

A.List latitude and longitude (to seconds) of the point where each discharge exits your property and name of receiving stream:

1.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

2.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

3.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

4.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

B.

Is this process water commingled with storm water prior to discharge?

Yes [

] No

[

]

C.

Has the process water been analyzed for presence of any known pollutants?

Yes [

]

No [

]

Attach the most recent copy of analysis.

D.

Give detailed description of wash water use, additives, location, ultimate disposal, etc.

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E. Do you wash interior of tank rail cars or tank trailers? Yes [ ] No [ ]

If yes, the facility cannot be covered under this General Permit. Please contact the Industrial Section of ADEM before proceeding.

F. How do you dispose of spent oil, hydraulic fluids and any other potential pollutants that you handle?

G. Does your facility use organic or petroleum based solvents in its washing operations? Yes [ ] No [ ]

If yes, the facility cannot be covered under this general permit. Please contact the Industrial Section of ADEM before proceeding.

GENERAL INFORMATION

Have you included a check for the application fee? Yes [ ] No [ ]

DO NOT SUBMIT APPLICATION AND PERMIT FEE SEPARATELY

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 or imprisonment for knowing violations.

SIGNATURES

Responsible Official Signature:

Date Signed:

Name and Official title (type or print):

NOTE: This Notice of Intent must be signed by the official representative of the facility who is: the owner, the sole proprietor of a sole proprietorship, a general partner for a partnership, or by a ranking elected official or other duly authorized representative for a unit of government or principal executive officer of at least the level of vice president, or a manager assigned or delegated in accordance with corporate procedures, with such delegation submitted in writing if required by the Department, who is responsible for manufacturing, production, or operating facilities and is authorized to make management decisions which govern the operation of the regulated. If the Notice of Intent is not signed, or is found to be incomplete, it will be returned.

Address:

Phone Number: (		)	Email address:

DISCHARGE MONITORING REPORTS (DMR) CONTACT – PLEASE COMPLETE

DMR Contact Name and Official title (type or print):

DMR Contact Address:

DMR Contact Phone Number: (		)

DMR Contact Email Address:

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NOI PREPARER

Name of Individual (type or print):

Name of Firm:

Address:

Phone Number:

(

)

Email address:

Please attach a map showing the location of the facility including major highways and/or landmarks.

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