Form 5600 Pm Mr0011 – Fill Out and Use This PDF

COAL ASH BENEFICIAL USE CERTIFICATION

1. COAL ASH GENERATION SITE INFORMATION

Name of Coal Ash Generation Facility

Company Name

Mailing Address

(Street Number and Name or P.O. Box)

(City)

(State)

(Zip Code + Four)

Ext.

Email address

Telephone Number

FAX Number

Location of Coal Ash Generation Facility

Municipality

County

State

Latitude

°

’

”

Longitude

°

’

”

Coal Ash Generation Facility Contact

(Last Name)

(First Name)

(MI)

(Title)

(Street Number and Name or P.O. Box)

(City)

(State)

(Zip Code + Four)

Ext.

Email Address

Telephone Number

FAX Number

Consultant or other contact

(Last Name)

(First Name)

(MI)

Ext.

Email Address

Telephone Number

FAX Number

IMPORTANT: Email contact will be used by the Department to provide reminders, information and forms. Please make sure the email address provided is regularly monitored. Notify RA-coalash@state.pa.us of changes.

2. BENEFICIAL USE

b. The following Beneficial Use is requested for this ash source:			Placement	Soil substitute/additive
If placement select all that apply:
Reclamation/Fill	Alkaline Addition	Low-permeability material

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5600-PM-MR0011 Rev. 9/2009

3.FUEL SOURCE

a.Provide information on the fuel source(s) used to produce coal ash for beneficial use. (Sources of fuel, location of source, blending, percentages, etc.)

b.List any non-coal materials (other than limestone) used in the combustion process (tire-derived fuel, paper, waste products, etc.) and justification for their use. If coproducts are used, include in the list and provide the determination information.

Describe how often each fuel source is used, the percentage of the fuel stream they constitute, the volume used, the chemical variability of these additional materials and any resulting chemical and/or physical property changes that may occur in the resulting ash. Identify particular chemical parameters that may increase in the ash due to use of these products. If any of these organic or inorganic parameters are not included on the Coal Ash Quality form, include sample analyses for them as part of the ash sampling requirements.

c.List all Bureau of Waste Management General Permits (WMGR) issued to this facility that authorize the operator to burn alternate fuels, mix residual waste, and/or authorize the beneficial use of ash generated by this facility. Attach a copy of the approval.

How frequently is ash generated from pure coal or waste coal only?

%

4.COAL ASH GENERATION PROCESS

a.Type of coal combustion:

Pulverized Coal

Circulating Fluidized Bed

Other (Describe):

b. Does this source location include multiple boilers/processes for generation of beneficially used ash?

Is the ash obtained from another location or process besides present-day generation?

If yes, describe each individual process in item 4.c. And, describe the ratio of ash from each process that will comprise the final source stream of ash to the mine site as part of 4.d.

c.Combustion process. Provide a description of the combustion process that generates coal ash for beneficial use. Describe pollution control processes utilized and how these affect the physical and chemical properties of the ash. For example, describe how NOx controls affect ash chemistry (e.g., effects on nitrogen in the ash). Provide diagrams, charts and tables as necessary to supplement this narrative description.

d.Collection and storage. Provide a description of the process that collects and stores coal ash to be used for beneficial use. Describe how ash is stored prior to beneficial use: type of storage (silo, impoundment, stockpile, etc.), lined/unlined, covered/uncovered, other material placed in storage with ash (other wastes, FGD material, etc.), age of material in storage, etc.

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5600-PM-MR0011 Rev. 9/2009

e.Indicate the expected percentage of each type of ash (fly, bottom, from each individual unit) for the final stream that goes to the mine site (i.e. 80% fly ash, 20% bottom ash). Describe any blending process.

f. How much ash will be produced per year from the entire plant (estimated)?					tons
	How much of this is expected to be used beneficially for mine sites in Pennsylvania?					% or
		tons.

5.PHYSICAL AND CHEMICAL CHARACTERISTICS OF COAL ASH

a.Describe the procedures used to obtain representative samples of beneficially used coal ash for analytical purposes (including timing and location of sampling, compositing and/or grab samples). A coal ash sampling plan must be developed describing the procedure to obtain a representative sample in accordance with EPA’s Test Methods for Evaluating Solid Waste, SW-846 and/or EPA’s Methods of Chemical Analysis of Water and Waste EPA 600/4-79-020.

b.Describe the amount of and processes by which water and/or other materials are added to or mixed with the coal ash at any point between collection at the generation site to final use at the mine site. Include the following: processing with additives to adjust the pH or alter any other properties of the ash, mixing with any other product. List every other materials deposited directly with the ash when placed at any mine site (plastic bed liners, soil, spoil, water treatment cake, etc.).

c.Analyze the coal ash and coal ash leachate for the constituents listed in Department form number 5600- FM-MR0012 “Coal Ash Quality Assessment”. Results from four (4) samples over a 2- to 6- month period within the last year must be submitted with the initial request for certification to the Department.

At least four (4) ash analyses are attached.

d.Contingency plan. If, at any time, the generator has knowledge that the ash does not meet quality criteria to be used at the beneficial use site, describe where this ash will be stockpiled, segregated and/or removed and disposed.

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5600-PM-MR0011 Rev. 9/2009

6. CERTIFICATION OF COAL ASH GENERATOR

I,, certify under penalty of law that I have personally examined and am

familiar with the information submitted herein and the attached analytical results. I believe the submitted information is true and correct to the best of my knowledge and belief. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

Sworn and Subscribed This

Day of

(month)	(year)	Signature of Responsible Official
		Title
		Name (Typed)
		Address

ACKNOWLEDGEMENT

COMMONWEALTH/STATE OF

COUNTY OF

On this

day of

,

, before me, the undersigned officer,

personally appeared the above named

, known to me (or satisfactorily proven)

to be the person(s) whose name(s) are subscribed to the within instrument, and acknowledged that he/she, in such capacity, being authorized to do so, executed the same for the purposes therein contained.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.

(Signature)

(Seal)

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