Form 3400 179 – Fill Out and Use This PDF

N OTICE OF IN TEN T

	State of Wisconsin	Information Summary for Nonmetallic Mining Operations
	Department of Natural Resources
		Form 3400-179 (03/2010) Page 1 of 5

As authorized in NR 216.26, Wi. Adm. Code, the Department of Natural Resources (the Department) will use the information requested on this form to determine if process wastewater and/or stormwater discharges from nonmetallic mining operations are eligible for coverage under the Wisconsin Pollutant Discharge Elimination System (WPDES) generalized permit No. WI-0046515-5. Submittal of a completed form to the Department is mandatory for any owner or operator of a nonmetallic mining operation that must apply for a permit in accordance with 40 CFR Part 122 or Chapter 283,Wi. Statutes. Discharge of wastewater from a nonmetallic mining operation which has not obtained coverage under the nonmetallic mining general permit or other applicable WPDES permit may result in forfeitures up to $10,000 per day, pursuant to s. 283.91, Stats. Personal identification information requested on this form may be used for other water quality program purposes.

Enter N/A for questions not applicable to your operation.

Section I: Parent Company/Owner Information – To be completed by all dischargers

Company/Owner Name

Contact Name	Last	First	MI	Title
Street Address			City	State	Zip Code
Phone Number		Fax Number		E-mail address (if available)

1. What are the Standard Industrial Classification (SIC) codes for your company’s nonmetallic mining operations?

 1410	Dimension Stone	 1420 Crushed and Broken Stone	 1440 Sand and Gravel
 1450	Clay, Ceramic & Refractory	 1470 Chemicals & Fertilizers	 1480 Nonmetallic Mineral Services

Others?

2.Has your company been issued any other wastewater (WPDES) permits that authorize the discharge of other wastewaters (such as from asphalt or concrete operations) to Wisconsin surface or underground waters?

 Yes

List the site names and WPDES permit numbers:

No

3.To the best of your knowledge, do any of your operations have process wastewater (from aggregate washing, pit dewatering, stack scrubbing, boiler blowdown, etc.) that contains any of the substances listed below? ______ Do any of your sites have stormwater that comes in direct contact with any of the substances listed below? ______ Check all the substances that apply.

 4,4'-DDD	 4,4'-DDE	 4,4'-DDT
 alpha – BHC	 Dieldrin	 Chlordane
 Mercury	 Mirex	 Octachlorostyrene
 Photomirex	 PCB	 Pentachlorobenzene
 1,2,3,4-Tetrachlorobenzene	 1,2,4,5-Tetrachlorobenzene	 2,3,7,8-Tetrachlorodibenzo-p-dioxin
 Toxaphene	 gamma - BHC (Lindane)	 tech. – BHC
 Hexachlorobenzene	 Hexachlorobutadiene

Other substances that are known to be harmful to human health or aquatic life (such as solvents or dissolved metals)

If you answered yes to either question above, and any of the above substances are checked, you may be required to segregate that wastewater and not discharge it to waters of the state. If you wish to pursue obtaining a permit to discharge wastewater containing these chemicals, indicate that you want the Department to send an application for a site specific WPDES discharge permit by checking here .

Check here  if none of the above substances are expected to be in the discharge.

4.To the best of your knowledge, have any leaks, spills, overflows or similar instances resulted in contamination of stormwater runoff from any of your nonmetallic mining operations in the last three years?

 Yes List the site names and actions taken to prevent future problems, (attach additional sheets if necessary).

No

N OTICE OF IN TEN T

	State of Wisconsin		Information Summary for Nonmetallic Mining Operations
	Department of Natural Resources
					(03/2010) Page 4 of 5
				Form 3400-179
	Section V: Signatory Requirements
	Information about the person completing this form:
	Name, Last	First		MI
	Street Address		City	State	Zip Code
	Phone Number	Fax Number		Email Address (if available)

Title of the person completing the form.

Check here if you should receive Discharge Monitoring Reports (DMR’s) for annual reporting of discharge test results.

Official Representative’s Signature. This form must be signed by the official representative of the permitted facility who is: the proprietor for a sole proprietorship; a general partner for a partnership; a principal executive officer, ranking elected official or other duly authorized representative for a unit of government; a member or manager for a limited liability company; or, for a corporation, an executive officer of at least the level of vice president, or by the executive officer’s authorized representative having overall responsibility for the operation of the facility. If this form is not signed below, or is found to be incomplete, it will be returned.

I certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief such information is true, complete and accurate.

Printed or Typed Name of Official Representative	Title
Signature of Official Representative	Date

MAIL COMPLETED APPLICATION TO:

Insert Regional Department Address Here

For Department

Use Only

Date Application Received:				Date permit coverage approved:
Status: ___	Denied	Internally Drained - Yes	No	AFSCI Frequency	–	Annual	1 per 3 years
___ Approved		SWPPP Required - Yes	No	Contaminant Control System Insp. - ¼ly			1 per 3 years
___	Specific permit	Site Number or FIN:		Visual Runoff Quality Check		- ¼ly	1 per 3 years

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