CLEAN WATER ACT NPDES PERMIT APPLICATION

PART I: APPLICANT INFORMATION

A. Facility Identification

Facility/Site Name: [________________________________]

Facility Address:
Street: [________________________________]
City: [________________________________]
State: [____] ZIP Code: [__________]
County: [________________________________]

Facility Location (if different from mailing address):
Latitude: [____° ____' ____" N]
Longitude: [____° ____' ____" W]

NPDES Permit Number (if renewal): [________________________________]

Permit Expiration Date (if renewal): [__/__/____]

B. Owner Information

Owner Name: [________________________________]
Owner Type: ☐ Individual ☐ Corporation ☐ Partnership ☐ Government ☐ Other: [________]

Owner Address:
Street: [________________________________]
City: [________________________________]
State: [____] ZIP Code: [__________]

Owner Contact:
Name: [________________________________]
Title: [________________________________]
Phone: [________________________________]
Email: [________________________________]

C. Operator Information (if different from owner)

Operator Name: [________________________________]
Operator Type: ☐ Individual ☐ Corporation ☐ Partnership ☐ Government ☐ Other: [________]

Operator Address:
Street: [________________________________]
City: [________________________________]
State: [____] ZIP Code: [__________]

Operator Contact:
Name: [________________________________]
Title: [________________________________]
Phone: [________________________________]
Email: [________________________________]

D. Application Type

☐ New Permit Application
☐ Permit Renewal Application
☐ Permit Modification Request
☐ Transfer of Permit Ownership

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PART II: FACILITY DESCRIPTION

A. Nature of Business

SIC Code(s): [________________________________]
NAICS Code(s): [________________________________]

Brief Description of Operations:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

B. Facility Type

☐ Industrial Facility
☐ Manufacturing
☐ Mining
☐ Power Generation
☐ Oil and Gas
☐ Other: [________________________________]

☐ Municipal Facility
☐ Publicly Owned Treatment Works (POTW)
☐ Municipal Separate Storm Sewer System (MS4)
☐ Combined Sewer System

☐ Commercial Facility

☐ Construction Activity (≥ 1 acre)

☐ Concentrated Animal Feeding Operation (CAFO)

C. Facility Operations

Number of Employees: [________]
Operating Schedule: [________] hours/day, [________] days/week, [________] weeks/year
Production Rate (if applicable): [________________________________]

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PART III: DISCHARGE INFORMATION

A. Outfall Description

Outfall Number	Outfall Location (Lat/Long)	Type of Discharge	Receiving Water Name	Receiving Water Type
[____]	[________________________________]	[________________]	[________________________________]	☐ River ☐ Lake ☐ Estuary ☐ Ocean ☐ Wetland
[____]	[________________________________]	[________________]	[________________________________]	☐ River ☐ Lake ☐ Estuary ☐ Ocean ☐ Wetland
[____]	[________________________________]	[________________]	[________________________________]	☐ River ☐ Lake ☐ Estuary ☐ Ocean ☐ Wetland
[____]	[________________________________]	[________________]	[________________________________]	☐ River ☐ Lake ☐ Estuary ☐ Ocean ☐ Wetland

B. Discharge Type and Flow

For Each Outfall:

Outfall Number: [____]

Type of Discharge:
☐ Process Wastewater
☐ Cooling Water (non-contact)
☐ Cooling Water (contact)
☐ Sanitary Wastewater
☐ Storm Water
☐ Combined
☐ Other: [________________________________]

Discharge Frequency:
☐ Continuous
☐ Intermittent: [________] times per [________]
☐ Seasonal: [________________________________]

Flow Rate:
Average Daily Flow: [________] MGD (million gallons per day)
Maximum Daily Flow: [________] MGD
Peak Hourly Flow: [________] MGD

C. Pollutant Characterization

Effluent Testing Data (attach laboratory reports):

Parameter	Units	Average Concentration	Maximum Concentration	Mass Loading (lbs/day)
BOD5	mg/L	[________]	[________]	[________]
TSS	mg/L	[________]	[________]	[________]
pH	S.U.	[________]	[________]	N/A
Temperature	°F	[________]	[________]	N/A
Oil & Grease	mg/L	[________]	[________]	[________]
Ammonia-N	mg/L	[________]	[________]	[________]
Total Nitrogen	mg/L	[________]	[________]	[________]
Total Phosphorus	mg/L	[________]	[________]	[________]
Fecal Coliform	CFU/100mL	[________]	[________]	N/A
[________________]	[________]	[________]	[________]	[________]
[________________]	[________]	[________]	[________]	[________]

Toxic Pollutants (40 CFR 122.21(g)(7)):
☐ Priority Pollutant Scan Completed
☐ Date of Analysis: [__/__/____]
☐ Laboratory: [________________________________]
☐ Results Attached: ☐ Yes ☐ No

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PART IV: TREATMENT SYSTEM DESCRIPTION

A. Wastewater Treatment

Treatment Type:
☐ Primary Treatment
☐ Secondary Treatment
☐ Advanced/Tertiary Treatment
☐ Disinfection
☐ No Treatment (explain): [________________________________]

Treatment Process Description:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

B. Treatment Units

Treatment Unit	Design Capacity	Current Loading	Year Installed
[________________________________]	[________________]	[________________]	[________]
[________________________________]	[________________]	[________________]	[________]
[________________________________]	[________________]	[________________]	[________]
[________________________________]	[________________]	[________________]	[________]

C. Residuals/Sludge Management

Sludge Generation Rate: [________] dry tons/year

Sludge Disposal Method:
☐ Land Application
☐ Landfill Disposal
☐ Incineration
☐ Composting
☐ Other: [________________________________]

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PART V: RECEIVING WATER INFORMATION

A. Receiving Water Characteristics

Receiving Water Name: [________________________________]
Water Body ID (if applicable): [________________________________]
Water Body Classification: [________________________________]

Designated Uses:
☐ Aquatic Life Support
☐ Primary Contact Recreation (Swimming)
☐ Secondary Contact Recreation
☐ Public Water Supply
☐ Agricultural Water Supply
☐ Industrial Water Supply
☐ Navigation
☐ Fish Consumption
☐ Other: [________________________________]

B. Water Quality Status

Impairment Status:
☐ Water body is on 303(d) list as impaired
☐ Water body is not impaired
☐ Impairment unknown

If Impaired, List Pollutants:
| Pollutant | TMDL Established | TMDL Date |
|-----------|------------------|-----------|
| [________________________________] | ☐ Yes ☐ No | [__/__/____] |
| [________________________________] | ☐ Yes ☐ No | [__/__/____] |
| [________________________________] | ☐ Yes ☐ No | [__/__/____] |

C. Sensitive Areas

☐ Outstanding Natural Resource Water (ONRW)
☐ Exceptional Value/High Quality Waters
☐ Wetlands Adjacent to Discharge Point
☐ Endangered Species Habitat
☐ Drinking Water Source Protection Area
☐ Shellfish Growing Area

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PART VI: STORMWATER INFORMATION (If Applicable)

A. Stormwater Exposure

Activities with Potential for Stormwater Exposure:
☐ Loading/Unloading Operations
☐ Outdoor Storage of Raw Materials
☐ Outdoor Manufacturing/Processing
☐ Waste Storage Areas
☐ Vehicle/Equipment Maintenance
☐ Fueling Areas
☐ Other: [________________________________]

B. Stormwater Management

Structural BMPs:
☐ Detention/Retention Basins
☐ Oil/Water Separators
☐ Sediment Traps/Basins
☐ Vegetated Swales
☐ Covered Storage Areas
☐ Other: [________________________________]

Non-Structural BMPs:
☐ Good Housekeeping Practices
☐ Spill Prevention Plan
☐ Preventive Maintenance Program
☐ Employee Training
☐ Visual Inspections
☐ Other: [________________________________]

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PART VII: COMPLIANCE HISTORY

A. Previous Violations

Has the facility received any violation notices in the past 5 years?
☐ Yes ☐ No

If Yes, describe:
| Date | Violation Type | Resolution Status |
|------|---------------|-------------------|
| [__/__/____] | [________________________________] | [________________________________] |
| [__/__/____] | [________________________________] | [________________________________] |
| [__/__/____] | [________________________________] | [________________________________] |

B. Pending Enforcement Actions

Are there any pending enforcement actions?
☐ Yes ☐ No

If Yes, describe:
[________________________________]
[________________________________]

C. Compliance Schedule

Is a compliance schedule requested?
☐ Yes ☐ No

If Yes, describe proposed schedule and milestones:
[________________________________]
[________________________________]

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PART VIII: REQUIRED ATTACHMENTS

Application Attachments Checklist

☐ Topographic Map (1" = 2,000' or larger scale) showing:
☐ Facility boundaries
☐ Outfall locations
☐ Receiving water bodies
☐ Wells within 1 mile
☐ Water intake structures within 1 mile

☐ Process Flow Diagram

☐ Site Plan showing:
☐ Building locations
☐ Treatment system
☐ Discharge points
☐ Drainage patterns

☐ Effluent Monitoring Data and Laboratory Reports

☐ Engineering Report (if new or modified discharge)

☐ Environmental Assessment (if required)

☐ Endangered Species Act Evaluation

☐ Historic Preservation Act Evaluation

☐ Application Fee: $[________]
☐ Check Enclosed ☐ Electronic Payment

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PART IX: CERTIFICATION

A. Certification Statement

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 and imprisonment for knowing violations.

B. Signatory Requirements

For a Corporation:
Signature must be by a responsible corporate officer (president, vice president, secretary, treasurer, or manager of manufacturing, production, or operating facility).

For a Partnership or Sole Proprietorship:
Signature must be by a general partner or proprietor, respectively.

For a Municipality, State, Federal, or Other Public Agency:
Signature must be by a principal executive officer or ranking elected official.

Signature: [________________________________]
Printed Name: [________________________________]
Title: [________________________________]
Date: [__/__/____]

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STATE-SPECIFIC NOTES

California

• State Water Resources Control Board and Regional Water Quality Control Boards administer NPDES
• Waste Discharge Requirements (WDRs) issued in lieu of NPDES permits
• California Ocean Plan applies to ocean discharges
• California Toxics Rule applies to inland waters and bays
• Additional CEQA review may be required

Texas

• TCEQ administers Texas Pollutant Discharge Elimination System (TPDES)
• Additional state water quality standards in 30 TAC Chapter 307
• Edwards Aquifer protection requirements may apply
• Antidegradation review required for new/increased discharges

Florida

• FDEP administers NPDES program
• Additional requirements for discharges to Outstanding Florida Waters
• Numeric nutrient criteria apply statewide
• Advanced wastewater treatment required in certain areas
• Total Maximum Daily Loads (TMDLs) affect many water bodies

New York

• NYSDEC administers State Pollutant Discharge Elimination System (SPDES)
• 6 NYCRR Parts 750-758 contain state regulations
• Additional requirements for discharges to classified waters
• Great Lakes requirements apply to certain discharges
• SEQRA review required for new permits

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SOURCES AND REFERENCES

• EPA NPDES Program: https://www.epa.gov/npdes
• 40 CFR Part 122 (NPDES Regulations)
• Clean Water Act (33 U.S.C. § 1251 et seq.)
• EPA Forms (Standard Form 1, 2A, 2B, 2C, 2D, 2E, 2F, 2S)

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This template provides general guidance for NPDES permit applications. Actual permit application forms and requirements vary by state and permit type. Always consult with the appropriate permitting authority and qualified environmental counsel before submitting a permit application.