NCS000570_Application Resubmittal_20190924

EPA Identification Number
NPDES Per Number
Facility Name
Form Approved 03105/19
OMB No. 2040-0004
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2.5
Facility Location
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route number, or other specific identifier
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County name
County code (if known)
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City, or town
State
ZIP code
SECTION
3. SIC
CODESra
AND NAICS 1
3.1
SIC Code(s)
Description (optional)
N
N
0
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0
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3.2
NAICS Code(s)
Description (optional)
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SECTION
4. OPERATOR
INFORMATION (40
4.1
Name of Operator
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4.2
Is the name you listed in Item 4.1 also the owner?
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❑ Yes ❑=No
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4.3
Operator Status
❑ Public —federal ❑ Public —state ❑ Other public (specify)
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❑:Private ElOther (specify)
4.4
Phone Number of Operator
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4.5
Operator Address
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Street or P.O. Box
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City or town
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ZIP code
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Email address of ope ator
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SECTION
5. INDIAN
LAND 1
5.1
Is the facility located on Indian Land?
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❑Yes o
EPA Form 3510-1 (revised 3-19) Page 2

EPA Identificationmeon Number
NPDES Permit Number
Facility Na
—7
Form Approved 03/05119
OMB No. 2040-0004
Form
U.S. Environmental Protection Agency
1
li EPA
Application for NPDES Permit to Discharge Wastewater
NPDES
GENERAL INFORMATION
1. ACTIVITIES
REQUIRINGSECTION •Dr
1.1
Applicants Not Required to Submit Form 1
1.1,1
Is the facility a new or existing publicly owned
1.1.2
Is the facility a new or existing treatment works
treatment works?
If yes, STOP. Do NOT complete No
treating domestic sewage?
If yes, STOP. Do NOT No
Form 1. Complete Form 2A.
complete Form 1. Complete
Form 2S.
1.2
Applicants Required to Submit Form 1
..
1.2.1
Is the facility a concentrated animal feeding
1.2.2
Is the facility an existing manufacturing,
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operation or a concentrated aquatic animal
commercial, mining, or silvicultural facility that is
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production facility?
currently discharging process wastewater?
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❑ Yes 4 Complete Form 1 No
Yes 4 Complete Form No
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Form 2B.
1 and Form 2C.
1.2.3
Is the facility a new manufacturing, commercial,
1.2.4
Is the facility a new or existing manufacturing,
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mining, or silvicultural facility that has not yet
commercial, mining, or silvicultural facility that
:3
commenced to discharge?
discharges only nonprocess wastewater?
d
❑ Yes 4 Complete Form 1 No
❑ Yes 4 Complete Form No
and Form 2D.
1 and Form 2E.
_
1.2.5
Is the facility a new or existingfacility whose
'—
discharge is composed entirely of stormwater
a
associated with industrial activity or whose
discharge is composed of both stormwater and
non-stormwater?
Yes 4 Complete Form 1 ❑ No
and Form 2F
unless exempted by
40 CFR
122.26(b)(14)(x) or
b 15).
SECTIONDD-
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2.1
Facility Name
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2.2
EPA Iden ification Number
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2.3
Facility Contact
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Name (first and last)
Ti le
Phone number
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Email ad ess
kt
2.4
Facility Mailing Address
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Strl or P.O. box
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.Pity or town
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ate
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ZIP p de
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EPA Form 3510-1 (revised 3-19) Page 1

EPA Identification Number NPDES Permit Number Facility Name
Farm Approved 03105/19
OMB No. 2040-0004
SECTIONR•
1
6.1 Existing Environmental Permits (check
all that apply and print or type the corresponding permit number for each)
EElNPDES
(discharges to surface
❑ RCRA (hazardous wastes)
ElUIC (underground injection of
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water)
fluids)
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PSD (air emissio )
ElNonattainment program (CAA)
ElNESHAPs (CAA)
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x
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section 404)
❑ Other (specify)
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SECTION1
7.1
Have you attached a topographic map containing all required information to this application? (See instructions for
CL
specific requirements.)
V/`Yes No ❑ CAFO—Not Applicable (See requirements in Form 2B.)
SECTIONOF
1
8.1
Describe the nature of your business. Si-
I �GJl rants, S.,r �c_ ACC u c- ck SvA wwA S� I ; ca�re<� car s�T--�-
H
3� S1� 1,i�vr, ` f aPP�0.x la opo pals.
STiaPa CYAC;ry 04 aQY Cod •ut, S1(;GaT�- rS a.pl5a
e Sr�/�s
m
0/k e- o! Sod - u,�►� (Aydedx� PG_ 4r Wa-Sre L,)Qt�,!
vt iS c-el"',
(n plar-e— All proc< SS water'
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!TZ M r 11, fNe Li tiL,-6 f i 2CT7 0✓► G V"d d SGXi r
� �� to P67-0
�Gr,�.•V,.l(� u �F ► r- Ls�� All to P07Q
COOLINGSECTION 9.
9.1
Does your facility use cooling water?
y
❑Yes FA No 4 SKIP to Item 10.1.
a, 2
9.2
Identify the source of cooling water. (Note that facilities that use a cooling water intake structure as described at
40 CFR 125, Subparts I J have 40 CFR 122.21(r).
and may additional application requirements at Consult with your
cY
NPDES permitting authority to determine what specific information needs to be submitted and when.)
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SECTION
1 VARIANCE
REQUESTS1 1
10.1
Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(m)? (Check all that
y
apply. Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)
Cr
❑ Fundamentally different factors (CWA ❑ Water quality related effluent limitations (CWA Section
Section 301(n)) 302(b)(2))
❑ Non -conventional pollutants (CWA ❑ Thermal discharges (CWA Section 316(a))
Section 301(c) and (g))
Not applicable
EPA Form 3510-1 (revised 3-19) Page 3
Ir,
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EPA Identification Number
NPDES Permit Number
Facility Name Form Approved 03105/19
OMB No. 2040-0004
SECTION
11. CHECKLIST
1 1
In Column 1 below, mark the sections of Form 1 that you have completed and are submitting with your application.
11.1
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to provide attachments.
Column 1
Column 2
❑� Section 1: Activities Requiring an NPDES Permit
❑ w/ attachments
Section 2: Name, Mailing Address, and Location
❑ wl attachments
Section 3: SIC Codes
❑ wl attachments
Section 4: Operator Information
❑ w/ attachments
0 Section 5: Indian Land
❑ wl attachments
Section 6: Existing Environmental Permits
❑ w/ attachments
E
❑ Section 7: Map
w/ topographic
additional attachments
ma ?01w/
Section 8: Nature of Business
❑ w/ attachments
❑'- Section 9: Cooling Water Intake Structures
❑ w/ attachments
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❑� Section 10: Variance Requests
❑ wl attachments
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Ma
�' Section 11: Checklist and Certification Statement
❑ w/ attachments
Y
11.2
Certification Statement
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1 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. 1 am aware that there are significant penalties for submitting false information,
including the possibility of fine and imprisonment for knowing violations.
Name (print or type first and last name)
Official title
D W A TT--)25
T)
1
ignature
ate signed
•1i J 1
L
EPA Form 3510-1 (revised 3-19) Page 4