Adem Form 391 – Fill Out and Use This PDF

J.Is this Notice of Intent for (check one):

1.First time issuance of a GENERAL Permit

2.Renewal of GENERAL Permit No. ALG

3.Modification of GENERAL Permit No. ALG

K.Are any of the discharges that you intend to be covered by this permit going to a municipal storm or municipal/private

	sanitary sewer? Yes [	] No [	] If Yes, then please contact the Industrial/Mining Permit Section of ADEM
	before proceeding.
L.	Name of surface water to which the municipal storm sewer discharges:
M. Have you notified the municipality by letter as required by 40 CFR 122.26(a)(4)? Yes						[	]	No [	]
N. Does the facility discharge to a public water supply, Outstanding Alabama Water or Outstanding Natural
	Resource Water stream segment as defined by ADEM Administrative Code R. 335-6-11-.02?							Yes [	] No [ ]
O.	Is your facility located in a coastal zone (within 10-foot contour of sea level)? Yes [					]	No[	]
P.	Date facility started or will start operations:

DSN001– 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

3.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

Type of Discharge

4.

Latitude

(

) ° (

) ‘ (

) “ N

Longitude

(

) ° (

) ‘ (

) “

W

Receiving Stream

Type of Discharge

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5.

Latitude (

) ° (

) ‘ (

) “ N

Longitude (

) ° (

) ‘ (

) “

W

Receiving Stream

Type of Discharge

B.

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/WaterDivision/WQuality/303d/WQ303d.htm

for 303(d)listed waters and http://www.adem.state.al.us/WaterDivision/WQuality/TMDL/TMDLs.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.

C.

If there are more than one of these discharges (in A. above), can they be sampled separately?

Yes

[

] No [

]

D.

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

Yes

[

] No

[

]

E.

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

]

No

[

]

F.

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

Yes

[

]

No

[

]

G.

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

[

]

No

[

]

H.

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

I.

Do you use biocides 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 freshwaster, the fathead minnow (pimephales promelas) and cladoceran (Ceriodaphnia dubia) are the required test organisms. For salt water, the organisms shall be sheepshead minnow, mysid, sea urchin, inland silverside.

(3)quantities to be used,

(4)frequencies of use,

(5)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

J.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 [	]
K.	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
L.	Is shock chlorination used at the facility? Yes [	] No [	]
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M.	Is any source water chlorinated? Yes [	]	No [	] If yes, explain use and list outfall number(s) from A. in this
	section.
N.	Is demineralizer wastewater discharged?	Yes	[	] No [	]
O.	Are there any know impacts on the receiving water as a result of the discharge? Yes [							] No [	]
	If yes, to what extent? ___________________________________________________________________________
P.	Is there a cooling water intake structure (CWIS) associated with this facility?					Yes [	] No [	]
Q.	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 P and Q is no, then a Cooling Water Intake Structure Form is not required. If the answer to either or both questions P and Q 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 DSN001 and DSN002 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.

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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.

Physical Address:

Phone Number: (		)
		DISCHANGE MONITORING REPORTS (DMR) CONTACT – PLEASE COMPLETE

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

DMR Contact Address:__________________________________________________

DMR Contact Phone Number: (						)
		PLEASE COMPLETE IF NOI IS PREPARED BY A CONSULTANT OR SOMEONE
						OTHER THAN AN EMPLOYEE OF THE FACILITY
Name of Individual (type or print):
Name of Firm:
Address:
Phone Number: (				)

Please attach a map showing the location of the facility including major highways and/or landmarks. The map should include the location of the discharge points.

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