Form Mo 780 0795 – Fill Out and Use This PDF

MISSOURI DEPARTMENT OF NATURAL RESOURCES

FOR AGENCY USE ONLY

WATER PROTECTION PROGRAM

CHECK NUMBER

FORM E – APPLICATION FOR GENERAL PERMIT

UNDER MISSOURI CLEAN WATER LAW

DATE RECEIVED

FEE SUBMITTED

1.00 BRIEFLY DESCRIBE THE NATURE OF YOUR BUSINESS

1.10

a.

This facility is now in operation under Missouri Operating Permit Number, or NPDES, MO –

and there

is not a proposed increase in design stormwater or wastewater flow.

b.

This facility is now in operation under Missouri Operating Permit Number MO –

and there is a proposed

increase in design stormwater or wastewater flow.

c.

This is a new permit (for a new facility).

d. Construction Permit if required by the General Permit.

If you checked either item b or c above then you may need to submit an antidegradation review. See instructions.

2.00 NAME OF FACILITY

2.10 ADDRESS (PHYSICAL)

CITY

STATE

ZIP CODE

3.00 OWNER

NAME

E-MAIL ADDRESS

PHONE NUMBER WITH AREA CODE

FAX NUMBER WITH AREA CODE

STREET

CITY

STATE

ZIP CODE

4.00 CONTINUING AUTHORITY

NAME

E-MAIL ADDRESS

PHONE NUMBER WITH AREA CODE

FAX NUMBER WITH AREA CODE

STREET

CITY

STATE

ZIP CODE

5.00 OPERATOR (if applicable)

NAME

PHONE NUMBER WITH AREA CODE

6.00 FACILITY CONTACT

NAME

PHONE NUMBER WITH AREA CODE

FAX NUMBER WITH AREA CODE

TITLE

7.00 FOR EACH OUTFALL GIVE THE LEGAL DESCRIPTION (ATTACH ADDITIONAL SHEETS AS NECESSARY)

Outfall Number

¼

¼

Sec.

T

R

__________ County

Outfall Number

¼

¼

Sec.

T

R

__________ County

7.10 FOR EACH OUTFALL LIST THE NAME OF THE RECEIVING WATER

Outfall Number

___________

Receiving Water ________________

Outfall Number

___________

Receiving Water ________________

7.20

Does the discharge(s) for which you are seeking a permit discharge to a combined sewer system?

Yes

No

7.40

Primary SIC Code ___________

7.50

If this application is for a storm water permit, please provide an attached list of any materials that are stored outside and exposed to storm water.

7.60

Attach a USGS 1” = 2,000’ scale map showing the location of the facility in relation to the local road system. Indicate on the map the facility, the receiving stream, the points of discharge

and the map section, township and range.

7.70

If this is an existing discharge, submit a summary of pollutants analyzed in the past two years.

7.80

If applying for a permit for an industrial site (i.e. stormwater), what is the method of domestic wastewater disposal? _________________

7.90

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

permit, I agree to abide by the Missouri Clean Water Law and all rules, regulations, orders and decisions, subject to any legitimate appeal available to applicant under the Missouri Clean

Water Law of Missouri Clean Water Commission.

A. NAME AND OFFICIAL TITLE (TYPE OR PRINT)

B. TELEPHONE NUMBER WITH AREA CODE

C. SIGNATURE

D. DATE SIGNED

MO 780-0795 (10-12)

INSTRUCTIONS

This form must be submitted with the application fee (listed below). Persons with more than one operating location shall obtain a general permit for each location unless other permitting arrangements are allowed by the terms of the general permit. Where multiple discharge points exist at a single operating location, one application may cover all the applicable discharges. If there are any questions concerning this form, please contact the appropriate regional office (see map available at www.dnr.mp.gov/regions/regions.htm).

Fees: Land Disturbance (Form G must be included) - $300 (due at application time only)

Ag Chem Fertilizer/Pesticide Storage- $150 due with application for new permits; $50/year while permit is in effect; no fee required with renewal application Concentrated Animal Feeding Operation, or CAFO - $150 (due at application time only)

Pesticide Applications - $150 due for the application for new permit and each year until expiration; $60/year thereafter; no fee required with renewal application. General Permit – Other (e.g., Motor Vehicle Salvage, Limestone Quarry, Petroleum Storage, Sand/Gravel Mining, etc.) - $150 due with application for new permits and each year until expiration; $60/year thereafter; no fee required with renewal application.

Construction Permit $750

1.00Give the name of the specific general permit you are applying for: (e.g. Motor Vehicle Salvage.) and describe the primary business conducted at this site. If you are unsure about the specific name for the general permit, contact the Water Protection Program, Water Pollution Branch at 573-751-6825.

As of April 27, 2012, a new general permit is available for private domestic no-discharge facilities with design flow of less than 50,000 gallons per day. These facilities must have no industrial contributors and are subject to specific requirements. Please see the web address below to review MO-G823 before applying for this permit.

1.10Fill out either item (a., item (b., item (c., or item (d. as applicable.

Each general permit may have specific antidegradation review requirements contained within it. Go to the following websites to verify your specific requirements: For MO-G permits visit www.dnr.mo.gov/env/wpp/permits/wpcpermits-general.htm.

For MO-R permits visit www.dnr.mo.gov/env/wpp/permits/wpcpermits-stormwater.htm.

Effective Sept. 1, 2008, facilities are required to use Missouri’s Antidegradation Rule and Implementation Procedure. This document is available on the Web at www.dnr.mo.gov/env/wpp/docs/aip-cwc-appr-050708.pdf. For more information please contact the Department at 800-361-4827 or 573-751-1300.

For some general permits, a construction permit is required prior to beginning construction of the facility. For other general permits, an exemption is provided from construction permit requirements. Please review the general permits at one of the web addresses noted above. For domestic wastewater treatment facilities, an engineering report, plans, and specifications as defined in 10 CSR 20-8.020 or 8.110 through 8.220 must be submitted for approval and issuance of a Construction Permit. If the facility is designed for greater than 22,500 gallons per day, the engineering report must be submitted and approved prior to submittal of the Form E Application, fee, plans and specifications. A Summary of Design Data must be submitted with the engineering plans and specifications.

2.00Name of facility – by what name is this facility known locally? (e.g., Southwest Sewage Treatment Plant or Oak Hill Mobile Home Park.)

2.10Give the street address of the facility. If the facility lacks a mailing address, give an accurate geographic description. (e.g., Intersection of Route A and M.)

3.00Owner – legal name and address of owner.

4.00Continuing Authority – permanent organization which will serve as the continuing authority for the operation, maintenance and modernization of the facility.

5.00Operator – name, certificate number of person operating the facility.

6.00Give name of person at the facility who can be contacted by the Department if necessary.

7.00An outfall is the point(s) at which wastewater is discharged. For storm water this may be the point(s) where water leaves the property. Outfalls should be given in terms of the legal description of the facility. Sufficient information should be submitted so the outfall may be located by Department staff.

7.10Receiving stream(s) – the name of the stream(s) to which the discharge is directed and any subsequent tributary until a lake or continuous flowing stream is reached.

7.30A combined sewer system is one in which the sanitary and storm sewers are one pipe. In Missouri, parts of Macon, Moberly, Cape Girardeau, St. Joseph, Kansas City, Sedalia and all of the city of St. Louis are on combined sewer systems. To find out information, consult with your municipal public works department or, if in St. Louis, the St. Louis Metropolitan Sewer District (MSD). If this discharge is to a combined sewer system, it is exempt from storm water permitting requirements. You do not need to file this application if it is for storm water discharges only.

7.40List only your primary Standard Industrial Classification, or SIC, code. The SIC system was devised by the U.S. Office of Management and Budget to cover all economic activities. The primary SIC code is that of the operation that generates the most revenue, or, secondly, employs the most personnel. To find the correct SIC code, contact the Missouri Department of Natural Resources at 573-526-6627 or refer to the following Web sites: www.census.gov/epcd/www/naicstab.htm or www.osha.gov/pls/imis/sicsearch.html. Do not list the North American Industry Classification System (NAICS) code.

7.50Please list anything stored outside, including wood pallets, empty storage barrels, waste disposal containers (except for a secured Dempsey dumpster), or anything that is a raw material, by-product, or product of your manufacturing activities.

If your facility is listed under any of the following SIC codes or major group codes, and you can certify that no materials are stored outside, then you are exempt from storm water permitting requirements. You do not need to file this application if it is for storm water discharges only. This information refers to the first two, first three, or all four numbers of your SIC code listed in 7.40 above. The SIC codes that are exempt from regulations if no materials are stored outside are: 20xx-23xx, 25xx, 265x, 267x, 27xx, 283x, 285x, 30xx, 31xx, 323x, 34xx-39xx, and 4221-4225.

7.60A map showing the facility in relation to the local roads and receiving streams is required. Attach a 1” = 2000’ scale U.S. Geological Survey topographic map, available from the department’s Division of Geology and Land Survey in Rolla at 573-368-2125.

7.70If this is an existing discharge, submit a list of pollutants analyzed in the past two years and any laboratory findings.

7.80Give the method of domestic wastewater disposal; identify the future method if the site is currently undeveloped. If public sewers, give name of sewer agency. If private system with a State Operating Permit, give name of facility and permit number. If other, please describe.

8.00Signature – all applications must be signed as follows and the signature must be original.

a.For a corporation, by an officer having responsibility for the overall operation of the regulated facility or activity or for environmental matters.

b.For a partnership or sole proprietorship, by a general partner or the proprietor (owner).

c.For a municipal, state, federal, or other public facility, by either a principal executive officer or by an individual having overall responsibility for environmental matters at the facility.

MO 780-0795 (10-12)