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EPR 10 Number (copy limit ►tam i of. Form 1) Form Approved. OMB No, 2040 -MSG
Please print or type in the unshaded areas only 1 NCD062567623 Approval expires 55-3 1 .92
Form
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United.States Environmental Protection Agency
Washington. ITC 20460
Application for Permit To Discharge Stormwater
,f>' Discharges Associated with Industrial Activit
Paperwork Reduction Act Notice
Pubtit reporting burden far this application is awimated to average 28.6 hour; per aPPlicsSon, including time for feuiewi"( instrucfions.
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information- Send
comments regarding the burden estimate, any other aspect of lois collection of information, Or suggestions for improving Ibis form, including
suggestions which may increase or reduce this burden to. Chief, Information Policy Branch, PW223. U.S. Environmental Protection Agency,
401 AA St., SW. Washington. DC 20460, or Director. Office of InformaWn and Regulatory Affairs. Office of Management and Budget,
•Nashingian, OG 20503. .
i. Cuttatl Locatinrt
#or each outfall list the latitude and fon itude of its location to the nearest 15 seconds and the name of she receiving water.
A. Outfall Number ❑. Receiving Water
Es it I . Latitude. C. Longitude (name)
001 J 035" 08' I5" 080° 57' 45" Steele Greer
002 035" 08' I5" 080° 57' 45" Steele Creek
003 035" 08' 15" 0800 57' 45" Steele Creek
004 035* 08' 15" 0809 57' 45" 1 Steele C eek
1l.Improvements
A. Are you now required by any Federal. State, or !coal authcrty to meet any ir•. p!e.mentation schedule for t"e constructicn. upkradin; a: '
be p -tion. of w2vowve. "a!r^e.^.t e_ anent or cra='ices or any other onvircrmental programs which may affect the N:s_hafc±s
de=ified in this application? This includes, but is not limited to, permit conditions, administrative or enforcement orders, enforcement
cornpiiance scheduie fetters. stipulations, court orders, and grantor loan conditions. No
a, Final
1. Identification of Conditions, 2. Affected Outfalls Compliance Oate
Agreements. Etc, number source of dfschar a 3. Brief Descri ion of Project a. req. b. rof.
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B. You may attach additional sheets describing any addilional water pollution (or other environmental projects which may affect your
discharges) you now have under way, or which you plan. Indicate whether each program is now under way or planned, and ind;cafe your
actual or planned Schedules for construction.
111. Site Dralna a Wa-
Attach a site map showing topography [or indicaling the outline of drainage areas served by the outfallfs) covered in the aoolication if a
topographic map is unavailablel depicting the facility including; each of its intake and discharge structures; the drainage area of each storms
water outfall; paved areas and buildings within the drainage area of each storm water outfall, each known past or present areas used for
Outdoor storage of disposal of significant materials, each existing structural control measure to "educe po#iutartis in storm water runoff,
materials loading and access areas, areas where pesticides, hertticides, soil conditioners and fertilizers are applied; each of its hazardous
was le treatment, starage or disposal units (including each area not required to have a RC RA pefmiI which is used for accumulating It a: at a0us
waste under 40 CFA 262.34); each well where fluids from the facility are injected underground; springs, and other surface water bodies which
feceive storm water discharges from the facility.
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