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Form 2M1 Instructions - Page 1 Return to: Oklahoma Department of 707 N. Robinson Revised June 2008 Environmental Quality P.O. Box 1677 previous editions Water Quality Division Oklahoma City, OK 73101-1677 are obsolete Municipal Permitting Section Oklahoma DEQ Application for Permit to Discharge Municipal/Domestic Wastewater Form 2M1 – Major Discharge PLEASE DETACH THESE INSTRUCTIONS AND RETURN ONLY THE COMPLETED APPLICATION FORM ITSELF. This form must be completed by all major facilities applying for a permit to discharge under DEQ’s Municipal OPDES Permit Program. See instructions for the submittal of applications and the public notice requirements. Form 2M1 Instructions - Page 2 OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY INSTRUCTIONS - DEQ FORM 2M1 (major) APPLICATION FOR PERMIT TO DISCHARGE MUNICIPAL/DOMESTIC WASTEWATER Form 2M1 must be completed by the owner/responsible official of a major municipal/domestic wastewater facility that wishes to discharge pollutants to waters of the State of Oklahoma. A major municipal/domestic wastewater facility is defined as a facility that discharges one million gallons per day (mgd) or greater. Please read the instructions below while completing Form 2M1 and respond to each item. The Oklahoma Department of Environmental Quality (DEQ) cannot evaluate an application until it is complete. If a particular item does not apply to the facility for which the application is being prepared, or if the correct answer is "NA" (for not applicable) indicate this on the application. If you have questions about any of the items, please contact DEQ or your local DEQ office for assistance. DO NOT attempt to complete the application form before reading these instructions. NOTE: DO NOT write in box marked " FOR DEQ USE ONLY". SECTION I 1. Give the legal name of the town, city, public entity or name of the person (if privately owned) legally responsible for operating and maintaining the facility. 2. Give the street address, P.O. Box, city, county, state, zip code, telephone number fax number, and e-mail address if applicable of the main office for the applicant in Item 1. This may or may not be the same location of the facility. 3. Give the name of the facility, the street address, telephone number fax number, and e-mail address if applicable and if it is different from the address in Items 1 and 2. 4. Give the physical location of the facility – longitude/latitude and legal description to a 10 acre tract, 1/4,1/4,1/4, Section, Township and Range. Note: This is the location of the treatment plant and it is not necessarily the same as the point of discharge. 5. Indicate whether this is a Public, Private, Federal or State owned facility. 6. Give the name, title, address, and telephone number, cell phone number, fax number, and e-mail address of a person who is familiar with the facility and information in the application and who may be contacted concerning the application. Form 2M1 Instructions - Page 3 7. Indicate whether the discharge is wastewater from a lagoon system, mechanical plant or, if other, explain. 8. Below is a list of definitions of the types of treatment listed in Item #8. Check more than one item if needed. Lagoon systems: A. Total Retention by Evaporation - Wastewater goes to a lagoon or series of lagoons which have no outlet or any other way to discharge. Lagoons cannot be classified total retention if they have any kind of operable outlet structure, even if it is not used. See DEQ Form 530E for Total Retention Facilities. B. Land Application - Wastewater is given preliminary treatment then applied to land (example: irrigation) in such a manner to insure that no runoff enters surface waters. C. Discharge to Receiving Water - Wastewater goes to a lagoon or series of lagoons and then to a receiving water through a designed outlet structure. Check this box even if the outlet structure is not being used. Mechanical Treatment Plants - Please name and describe the mechanical treatment process used at your facility. (Examples: trickling filter, activated sludge, extended air, sequential batch reactor, oxidation ditch) Other - Please name and explain any process used at your facility other than those listed above. 9. If the facility uses chlorine or any other halogen, indicate whether the facility dechlorinates or dehalogenates before discharging to a receiving water. If chlorine or any other halogen is used as a disinfecting agent to meet bacteria limits, or for other purposes, a residual limit of no-measurable value will be included in the permit. Dechlorination or dehalogenation will be necessary to meet the limit. Please indicate whether dechlorination or dehalogenation is provided at your facility. 10. Design flow is established when the construction permit is approved. Design Flow: the quantity of wastewater in million gallons per day (mgd) the facility was designed to treat in one day. List up to 3 decimal places. Example: 3.120 = 3 million one hundred twenty thousand gallons per day. 11. Enter the number for each discharge point and the average quantity of treated wastewater discharged each day from each pipe. 12. Name the body of surface water that receives treated wastewater. If the receiving stream does not have a name, please indicate what named creek or river downstream receives the tributary flow, and fill out as "tributary of ________ Creek Form 2M1 Instructions - Page 4 or River." Check the item which indicates the frequency of wastewater discharges. continuous: discharging without interruption batch: discharging several times during the day (i.e. from a sequential batch reactor facility intermittent: sporadic discharges during the year seasonal: discharging only during certain periods during the year Give the location of the point of discharge to the receiving water. This may be different than the location of the facility. In giving the legal description, provide both the latitude-longitude and 1/4, 1/4, 1/4, Section, Township and Range. Attach addition sheets if necessary to describe additional outfalls. 13. Indicate whether the higher influent flow caused by heavy rains is diverted and discharged resulting in a bypass of partially or completely treated wastewater or if it is stored for later treatment (as in a holding basin). 14. Number 14. A through B of the application concerns the treatment and disposal of biosolids/sludge. A. Common biosolids/sludge treatment processes are aeration, lime stabilization, heat stabilization etc. B 1. Sludge management plan numbers start with SMP and usually have 7 numbers. In giving the land application sites, provide the legal description 1/4, 1/4, 1/4, Section, Township and Range and County. Attach additional sheet if facility has more than 3 sites. B 2. The permittee shall be certain that all landfills used for sewage sludge disposal comply with the state and federal regulations for landfills and solid waste disposal. 15. State if any industries in the community discharge industrial wastewater to the sewer system. If the answer to this question is yes, submit Section II of the application form for each significant industrial facility. Identify any industrial facilities that are “Categorical”. Categorical industries are listed at 40 CFR 122 Appendix A - NPDES Primary Industry Categories (See Attachment 1, page 6). Indicate what type of controls are in place to deal with industrial discharges to the treatment system. 16. Maps and Drawings - A schematic of wastewater flow through the facility and a location map of the facility are required. All sheets should be letter size with margins for filing and binding and on paper suitable for reproduction. Discharge points should be identified with discharge serial numbers. All sheets must include the applicant's name, facility location and date of drawing. Form 2M1 Instructions - Page 5 17. Any information, laboratory analysis, concerning the pollutants in Table 1 should be entered in the table or results attached to the application. 18. Attachments 2 and 3 (Pages 6 through 10) are enclosed for your convenience. Attachment 2 is 40 CFR 122 Appendix D listing all the priority pollutants (Tables I, II, III, IV and V). Attachment 3 lists the approved test methods for analyses of wastewater and associated minimum quantification levels as required. 19. Table V, of 40 CFR 122, Appendix D is reproduced in attachment 2 (Page 7) of these instructions 20. The results for any and all analysis of pollutants for the previous three years should be put in a table and attached to the application. 21. If the answer to this question is yes a landowner notification form (found at http://www.deq.state.ok.us/ ) must be sent to the landowner and the applicant’s certifying official must initial the box certifying that this has been done. 22. All other information regarding the facility having to do with the environmental/operational permits including maps, process diagrams, or chemical analysis should be included with the permit application. SECTION II 1. Give the name, title, address, and telephone number, cell phone number, fax number, and e-mail address of a person who is familiar with the industrial facility and information in the application and who may be contacted concerning the application. 2. All products and by-products for this facility should be listed. 3. Identify any industrial facilities that are “Categorical”. Categorical industries are listed at 40 CFR 122 Appendix A - NPDES Primary Industry Categories (See Attachment 1, page 6). The SIC codes can be found in or should be obtained from the contact described above. 4. Please specify the product produced or raw materials used to produce the final product, how many are produced, and the unit of measurement in which the final product or raw materials are measured. 5. Indicate the volume of wastewater discharged into the municipal system in gallons per day and check the item which indicates the frequency of wastewater discharges. continuous: discharging without interruption Form 2M1 Instructions - Page 6 intermittent: sporadic discharges during the year 6. Indicate if the industrial facility pretreats its wastewater prior to entering the municipal collection system. 7. List the pollutants and maximum concentrations of the pollutants in the industrial facilities wastewater. The information provided in the application will be considered in the evaluation and processing of a discharge permit for the referenced facility. Be advised that test procedures used in the analyses of influents, effluents and sludge, must conform to approved EPA methodology or it will not be accepted for the discharge permit evaluation. Please note that the application must be signed by the authorized chief elective or executive officer of the applicant, or by the applicant if an individual. The authorized signature must be notarized. An example of a common mistake is when a Public Works Authority Chairman signs the application as - John Doe, Mayor. The Mayor is not the legal official of the PWA, the chairman is, even if the individual holds both positions. Please read the certification carefully. There are significant penalties for submitting false information on this application form. Form 2M1 may be separated from the instruction before mailing. NOTICE FOR ALL APPLICANTS Upon filing an application for a new permit, renewal of an existing permit, or major modification of an existing permit with the Department, the applicant shall publish a notice of the filing in a local newspaper which contains: (1) Date of filing; (2) Name and address of the applicant; (3) Type of wastewater discharge and permit sought; (4) Location, including legal description and street address of facility and discharging point or points; (5) Name of receiving water; (6) Name, address and telephone number of contact person for applicant; and (7) Locations where application may be reviewed. Form 2M1 Instructions - Page 7 Attachment 1 40 CFR Ch. 1 Pt. 122 APPENDIX A-NPDES Primary INDUSTRY CATEGORIES Any permit issued after June 30, 1981 to dischargers in the following categories shall include effluent limitations and a compliance schedule to meet the requirements of section 301(b)(2)(A),(C),(D),(E), and (F) of CWA, whether or not applicable effluent limitations guidelines have been promulgated See §§ 122.44 and 122.46. Industry Category Adhesives and sealants Aluminum forming Auto and other laundries Battery manufacturing Coal mining Coil coating Copper forming Electrical and electronic components Electroplating Explosives manufacturing Foundries Gum and wood chemicals Inorganic chemicals manufacturing Iron and steel manufacturing Leather tanning and finishing Mechanical products manufacturing Ore mining Organic chemicals manufacturing Paint and ink formulation Pesticides Petroleum refining Pharmaceutical preparations Photographic equipment and supplies Plastics processing Plastic and synthetic materials manufacturing Porcelain enameling Printing and Publishing Pulp and paper mills Rubber processing Soap and detergent manufacturing Steam electric power plants Textile mills Timber products processing 40CFR 261.20 Subpart C-Characteristics of Hazardous Waste § 261.20 General (a) A solid waste, as defined in § 261.2, which is not excluded from regulation as a hazardous waste under § 261.4(b), is a hazardous waste if it exhibits any of the characteristics identified in this subpart. {Comment: § 262.11 of this chapter sets forth the generator’s responsibility to determine whether his waste exhibits one or more of the characteristics identified in this subpart} (b) A hazardous waste which is identified by a characteristic in this subpart is assigned every EPA Hazardous Waste Number that is applicable as set forth in this subpart. This number must be in compliance with the notification requirements of section 3010 of the Act and all applicable recordkeeping and reporting requirements under parts 262 through 265, 268, and 270 of this chapter. (c) For purposes of this subpart, the Administrator will consider a sample obtained using any of the applicable sampling methods specified in Appendix I to be a representative sample within the meaning of Part 260 of this chapter. {Comment: Since the Appendix I sampling methods are not being formally adopted by the Administrator, a person who desires to employ an alternative sampling method is not required to demonstrate the equivalency of his method under the procedures set forth in §§ 260.20 and 260.21.} {45FR 33119.May 1980. As amended at 51 FR 40636. Nov. 7, 1986: 55 FR 22684. June 1, 1990} Form 2M1 Instructions - Page 8 Attachment 2 Appendix D to Part 122 – NPDES Permit Application Testing Requirements (§ 122.21) 15B butylbenzyl phthalate Bryllium, Total Carbofuran Table II - Organic Toxic Pollutants 16B 2 chloronaphthalene Cadmium, Total Carbon disulfide In Each Of Four Fractions In 17B 4 chlorophenyl phenyl ether Chromium, Total Chloropyrifos Analysis By Gas Chromatogra- 18B chrysene Copper, Total Coumaphos phy/Mass Spectroscopy (GS/MS) 19B dibenzo(a,h)anthracene Lead, Total Cresol Volatiles 20B 1,2 dichlorobenzene Mercury, Total Crotonaldehyde IV acrolein 21B 1,3 dichlorobenzene Nickel, Total Cyclohexane 2V acrylonitrile 22B 1,4 dichlorobenzene Selenium, Total 2,4-D (2,4-Dichlorophenoxy acetic acid) 3V benzene 23B 3,3 dichlorobenzidine Silver, Total Diazinon 5V bromoform 24B diethyl phthalate Thallium, Total Dicamba 6V carbon tetrachloride 25B dimethyl phthalate Zinc, Total Dichlobenil 7V chlorobenzene 26B di-n-butyl phthalate Cyanide, Total Dichlone 8V chlorodibromomethane 27B 2,4 dinitrotoluene Phenols, Total 2,2-Dichloropropionic acid 9V chloroethane 28B 2,6 dinitrotoluene Dichlorvos 10V 2-chloroethylviny ether 29B di-n-octyl phthalate Table IV-Conventional and Noncon- Diethyl amine 11V chloroform 30B 1,2-diphenylhydrazine(as azobenzene) ventional Pollutants Required Dimethyl amine 12V dichlorobromomethane 31B fluroranthene to be tested by existing Dis- Dintrobenzene 14V 1,1 dichloroethane 32B fluorene chargers if expected to be present Diquat 15V 1,2 dichloroethane 33B hexachlorobenzene Disulfoton 16V 1,1 dichloroethylene 34B hexachlorobutadiene Bromide Diuron 17V 1,2 dichloropropane 35B hexachlorocyclopentadiene Chlorine, Total Residual Epichlorohydrin 18V 1,3 dichloropropylene 36B hexachloroethane Color Ethion 19V ethylbenzene 37B indeno(1,2,3-cd)pyrene Fecal Colliform Ethylene diamine 20V methyl bromide 38B isophorone Fluoride Ethylene dibromide 21V methyl chloride 39B napthalene Nitrate-Nitrite Formaldehyde 22V methylene chloride 40B nitrobenzene Nitrogen, Total Organic Furfural 23V 1,1,2,2 tetrachloroethane 41B N-nitrosodinethylamine Oil and Grease Guthion 24V tetrachloroethylene 42B N-nitrosodi-n-propylamine Phosphorus, Total Isoprene 25V toluene 43B N-nitrosodiphenylamine Radioactivity Isopropanolamine Dodecylbenzenesulfonate 26V 1,2-trans-dichloroethylene 44B phenanthrene Sulfate Kelthane 27V 1,1,1 trichloroethane 45B pyrene Sulfide Kepone 28V 1,1,2 trichloroethane 46B 1,2,4 trichlorobenzene Sulfitee Malathion 29V trichloroethylene Pesticides Surfactants Mercaptodimethur 31V vinyl chloride 1P aldrine Aluminum, Total Methoxychior Acid Compounds 2P alpha-BHC Barlum, Total Methyl mercaptan 1A 2 chlorophenol 3P beta-BHC Boron, Total Methyl methacrylate 2A 2,4 dichlorophenol 4P gamma-BHC Cobalt, Total Methyl parathion 3A 2,4 dimethylphenol 5P delta/BHC Iron, Total Mevinphos 4A 4,6 dinitro-o-cresol 6P chlordane Magnesium, Total Mexacarbate 5A 2,4 dinitrophenol 7P 4,4 DDT Molybdenum, Total Monoethyl amine 6A 2 nitrophenol 8P 4,4 DDE Manganese, Total Monomethyl amine 7A 4 nitrophenol 9P 4,4 DDD Tin, Total Naled 8A p-chloro-m-cresol 10P dieldrin Titanium, Total Mapthenic acid 9A pntachlorophenol 11P alpha-endosulfan Nitrotoluene 10A phenol 12P beta-endosulfan Table V-Toxic Pollutants and Haz- Parathion 11A 2,4,6 trichlorophenol 13P endosulfan sulfate ardous Subtances Required To Phenolsulfanate Base/Neutral 14P endrin Be Identified By Existing Dis- Phosgene 1B acenaphthene 15P endrin aldehide chargers if expected to be present Propargite 2B acenaphthylene 16P heptachlor Propylene oxide 3B anthracene 17P heptachlor epoxide Toxic Pollutants Pyrethrins 4B benzidine 18P PCB-1242 Quinoline 5B benzo(a)anthracene 19P PCB-1254 Asbestos Resorcinol 6B benzo(a)pyrene 20P PCB-1221 Hazardous Subtances Strontium 7B 3,4 benzofluoranthene 21P PCB-1232 Acetaldehyde Strychnine 8B benzo(ghi)perylene 22P PCB-1248 Allyl alcohol Styrene 9B benzo(k)fluoranthene 23P PCB-1260 Allyl chloride 2,4,5-T (2,4,5-Trichlorophenoxy acetic acid) 10B bis(2-chloroethoxy)methane 24P PCB-1016 Amyl acetate TDE (Tetrachlorodiphenylethane) 11B bis(2-chloroethyl)ether 25P toxaphene Anlline 2,4,5-TP {2(2,4,5-Trichlorophenoxy) propa- 12B bis(2-chloroisopropyl)ether Benzonitrile noci acid} 13B bis(2-ethylhexyl)phthalate Table III-Other Toxic Pollutants Benzyl chloride Trichlorofan 14B 4 bromophenyl phenyl ether (Metals and Cyanide) and Total Butyl chloride Triethanolamine dodecylbenzenesulfonate Phenols Butyl acetate Triethylamine Butylamine Trimethylamine Antimony, Total Captan Uranium Arsenic, Total Carbaryl Vanadium Vinyl Acetate Xylene Xylenol Zirconium Form 2M1 Instructions - Page 9 ATTACHMENT 3 MINIMUM QUANTIFICATION LEVELS (MQLs) REQUIRED MQL METALS AND CYANIDE (ug/L) EPA METHOD Antimony (Total)1 60 200.7 Arsenic (Total)1 10 206.5 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Beryllium (Total)1 5 200.7 Cadmium (Total) 1 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Chromium (Total)1 10 200.7 Chromium (3+)1 10 200.7 Chromium (6+)1 10 200.7 Copper (Total) 10 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Lead (Total) 5 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Mercury (Total)1 0.2 245.1 revision 3.0 (1994) Molybdenum (Total) 30 200.7 Nickel (Total)1 (Freshwater) 40 200.7 Nickel (Total) (Marine) 5 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Selenium (Total)1 5 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Silver (Total) 2 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Thallium (Total)1 10 279.2 revision Zinc (Total)1 20 200.7 Cyanide (Total)1 10 335.4 DIOXIN 2,3,7,8-Tetrachloro-dibenzo- p-dioxin (TCDD)2 0.00001 1613 VOLATILE COMPOUNDS Acrolein3 50 624 Acrylonitrile3 50 624 Benzene3 10 624 Bromoform4 10 624 Carbon Tetrachloride4 10 624 Chlorobenzene4 50 624 Chlorodibromomethane4 10 624 Chloroethane 50 624 2-Chloroethylvinyl Ether3 10 624 Chloroform4 10 624 Dichlorobromomethane4 10 624 1,1-Dichloroethane4 10 624 1,2-Dichloroethane4 10 624 1,1-Dichloroethylene4 10 624 1,2-Dichloropropane4 10 624 1,3-Dichloropropylene4 10 624 Form 2M1 Instructions - Page 10 Ethylbenzene4 10 624 Methyl Bromide (Bromomethane) 50 624 Methyl Chloride (Chloromethane) 50 624 Methylene Chloride4 20 624 1,1,2,2-Tetrachloroethane4 10 624 Tetrachloroethylene4 10 624 Toluene4 10 624 1,2-Trans-Dichloroethylene4 10 624 1,1,1-Trichloroethane4 10 624 1,1,2-Trichloroethane4 10 624 Trichloroethylene4 10 624 Vinyl Chloride4 10 624 ACID COMPOUNDS 2-Chlorophenol4 10 625 2,4-Dichlorophenol4 10 625 2,4-Dimethylphenol1 10 625 4,6-Dinitro-o-Cresol1 (12 methyl 4,6-dinitrophenol)4 50 625 2,4-Dinitrophenol4 50 625 2-Nitrophenol4 20 625 4-Nitrophenol4 50 625 p-Chloro-m-Cresol (4 chloro-3-methylphenol)1 10 625 Pentachlorophenol4 50 625 Phenol4 10 625 2,4,6-Trichlorophenol4 10 625 BASE/NEUTRAL COMPOUNDS Acenaphthene4 10 625 Acenaphthylene4 10 625 Anthracene4 10 625 Benzidine3 50 625 Benzo (a) Anthracene4 10 625 Benzo (a) Pyrene4 10 625 3,4-Benzofluranthene4 10 625 Benzo (ghi) Perylene 20 625 Benzo (k) Fluranthene4 10 625 Bis (2-Chloroethoxy) Methane4 10 625 Bis (2-Chloroethyl) Ether4 10 625 Bis (2-Chloroisopropyl) Ether4 10 625 Bis (2-Ethylhexyl) Phthalate4 10 625 4-Bromophenyl Phenyl Ether4 10 625 Butylbenzyl Phthalate4 10 625 2-Chloronapthalene4 10 625 4-Chlorophenyl Phenyl Ether4 10 625 Chrysene4 10 625 Dibenzo (a,h) Anthracene4 20 625 1,2-Dichlorobenzene4 10 625 1,3-Dichlorobenzene4 10 625 1,4-Dichlorobenzene4 10 625 3,3’-Dichlorobenzidine 50 625 Diethyl Phthalate4 10 625 Dimethyl Phthalate4 10 625 Di-n-Butyl Phthalate4 10 625 2,4-Dinitrotoluene4 10 625 2,6-Dinitrotoluene4 10 625 Di-n-octyl Phthlate4 10 625 1,2-Diphenylhydrazine3 20 625 Fluoranthene4 10 625 Form 2M1 Instructions - Page 11 Fluorene4 10 625 Hexachlorobenzene4 10 625 Hexachlorobutadiene4 10 625 Hexachlorocyclopentadiene4 10 625 Hexachloroethane 20 625 Indeno (1,2,3-cd) Pyrene 20 625 (2,3-o-phenylene pyrane) Isophorone4 10 625 Naphthalene4 10 625 Nitrobenzene4 10 625 N-nitrosodimethvlamine 50 625 N-nitrosodi-n-propylamine 20 625 N-nitrosodiphenylamine 20 625 Phenanthrane4 10 625 Pyrene4 10 625 1,2,4-Tricfhlorobenzene4 10 625 PESTICIDES Aldrin1 0.05 608 Alpha-BHC1 0.05 608 Beta-BHC1 0.05 608 Gamma-BHC (Lindane)1 0.05 608 Delta-BHC1 0.05 608 Chlordane1 0.2 608 4,4’-DDT1 0.1 608 4,4’-DDE (p,p-DDX)1 0.1 608 4,4’-DDD (p,p-TDE)1 0.1 608 Dieldrin1 0.1 608 Alpha-endosulfan1 0.1 608 Beta-endosulfan1 0.1 608 Endosulfan sulfate1 0.1 608 Endrin1 0.1 608 Endrin aldehyde1 0.1 608 Heptachlor1 0.05 608 Heptachlor epoxide1 0.1 608 (BHC-hexachlorocyclohexane) PCB-12421 1.0 608 PCB-1254 1.0 608 PCB-1221 1.0 608 PCB-1232 1.0 608 PCB-1248 1.0 608 PCB-1260 1.0 608 PCB-1016 1.0 608 Toxaphene1 5.0 608 1 Based on Contract Required Quantitation Level (CRQL) developed 2 Dioxin National Strategy 3 No CRQL established 4 CRQL basis, equivalent to MQL MQL based on 3.3 times Level of Detection (LOD) in 40 CFR 136, Appendix B Form 2M1 - Page 1 OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY APPLICATION FOR PERMIT TO DISCHARGE MUNICIPAL/DOMESTIC WASTEWATER UNDER THE OKLAHOMA POLLUTANT DISCHARGE ELIMINATION SYSTEM (OPDES) FORM 2M1 (major) FOR DEQ USE ONLY Application/Permit Number OK00____________________ Facility ID No. _________________ Date Received: ____________________________________ SIC Code: _________________________________________ If a proposed facility, give estimated date of completion: _________________________ DEQ PERMIT ENGINEER: ____________________________ DO NOT attempt to complete this application without reading the instructions! SECTION I 1. Legal name of applicant: ___________________________________________________________________________________________________ 2. Mailing address of applicant: Street Address or PO Box ______________________________________________________________________________ City _______________________ County __________________ State ___________________ Zip Code ________________ Telephone (____)_______________________________ Fax (_____)____________________________________________ E-mail Address ______________________________________________________________________________________ 3. Name and address of facility: Facility Name________________________________________________________________________________________ Street Address _______________________________________________________________________________________ City ________________________ County _________________ State ___________ Zip Code________________________ Telephone (____)_______________________________ Fax (_____)____________________________________________ E-mail Address ______________________________________________________________________________________ 4. Location of discharging facility (e.g., NE ¼ , SW ¼ , SE ¼ , Section 1, Township 2 North, Range 3 West): Legal Description of Facility Location ______ __, ______ __, _____ __, Section ______, Township _____, Range ________ Latitude: _______________N Longitude: _______________W 5. Type Ownership: Public ( ) Private ( ) Federal ( ) State ( ) 6. Contact Person: Name and Title _______________________________________________________________________________________ Address ____________________________________________________________ City _____________________________ County _________________ State ______________ Zip Code _____________ Telephone (_____) ____________________ Fax (_____) ____________________ Cell Phone (_____) ____________________ E-mail Address _______________________________________________________________________________________ Form 2M1 - Page 2 7. Type of discharge: ______ A. Wastewater from lagoon system ______ B. Wastewater from mechanical plant ______ C. Other (specify) ____________________________________________________________________________ 8. Type of treatment: ________ A. Lagoon system with total retention by evaporation (Does not require this form, it requires Form 583-B) ________ B. Lagoon system with effluent used for land application (Does not require this form, it requires Form 852-NIWP) ________ C. Lagoon system with effluent discharge to receiving water ________ D. Lagoon system with effluent discharge and effluent used for land application ________ E. Mechanical Plant: (please describe briefly) _____________________________________________________ ___________________________________________________________________________________________________ 9. Is chlorine or any other halogen used at this facility? ( ) Yes ( ) No If yes, is dechlorination or dehalogenation used at this facility? (See instructions) ( ) Yes ( ) No Is an ultraviolet (UV) system used at this facility? ( ) Yes ( ) No 10. Design flow of facility in million gallons per day (mgd) ____________________________________________________ 11. Discharge point number Total volume presently discharged (List all outfalls) million gallons per day (mgd) 001 ________________ 002 (if applicable) ________________ 003 (if applicable) ________________ 12. Legal description(s) of all discharge point(s): Outfall 001: Name of receiving water(s): ___________________________________________________________________________ Discharge is (check one) Continuous ( ) Intermittent ( ) Seasonal ( ) Latitude: _______________N Longitude: _______________W Legal Description of discharge point ______ __, ______ __, _____ __, Section ______, Township _____, Range ________ Outfall 002 (if applicable): Name of receiving water(s): ___________________________________________________________________________ Discharge is (check one) Continuous ( ) Intermittent ( ) Seasonal ( ) Latitude: _______________N Longitude: _______________W Legal Description of discharge point ______ __, ______ __, _____ __, Section ______, Township _____, Range ________ Form 2M1 - Page 3 Outfall 003 (if applicable): Name of receiving water(s): ___________________________________________________________________________ Discharge is (check one) Continuous ( ) Intermittent ( ) Seasonal ( ) Latitude: _______________N Longitude: _______________W Legal Description of discharge point ______ __, ______ __, _____ __, Section ______, Township _____, Range ________ 13. During periods of heavy rain, is the increased flow: ( ) Bypassed to the receiving stream with no treatment ( ) Given partial treatment and discharged ( ) Given complete treatment and discharged ( ) Stored for later treatment 14. Biosolids/Sludge generated by this facility: A. Current biosolids/sludge treatment process. (Please explain) ___________________________________________________________________________________________ ___________________________________________________________________________________________ B. Amount of biosolids/sludge produced (dry metric tons/year)____________________________________________ 1. Land application of biosolids Sludge management plan, if any: Sludge management permit number ___________________ approved by the Department of Environmental Quality or the Oklahoma State Department of Health on ___________________ Location(s) of current land application site(s) (legal description to the nearest 10 acres). Site 1: ______, ______, _____, Section ______, Township _____, Range _______ County ________ Site 2 (if applicable): ______, ______, _____, Section ______, Township _____, Range _______ County _______ Site 3 (if applicable): ______, ______, _____, Section ______, Township _____, Range _______ County ________ 2. Landfilled sludge Sludge disposition plan, if any: Sludge disposition permit number (if applicable) ___________________ approved by the Department of Environmental Quality or the Oklahoma State Department of Health on ___________________ Name of Landfill ___________________________________________________________________________ Landfill permit number ______________________________________________________________________ 15. Does this facility receive industrial wastewater? Yes ( ) No ( ) If "Yes", Submit Section II of this form (attached) for each significant industrial facility discharging to the sewer system. Are industrial discharge(s) to the system(s) controlled by Form 2M1 - Page 4 ( ) Ordinance ( ) Pretreatment Program Form 2M1 - Page 5 16. Maps and drawings - Attach all required maps and drawings to the back of this application. (see instructions) 17. Complete attached Table 1 detailing both influent and effluent pollutants. 18. Submit test results of a composite sample of effluent, or when appropriate grab samples, for all pollutants listed in 40 CFR 122, Appendix D, Table II and Table III. 19. Submit quantitative data on pollutants listed in 40 CFR 122, Appendix D, Table V that are known or reasonably expected to be discharged. 20. Tabulations of all results collected pertaining to the quality and quantity of all toxic pollutants identified as a constituent in the publicly owned treatment works (POTW) effluent and regulated or prohibited by an Industrial Waste Ordinance during the period from three years prior to the date of this application to the present. 21. Landowner Notification (THIS SECTION MUST BE COMPLETED PRIOR TO SUBMISSION OF THE APPLICATION – THE APPLICATION WILL AUTOMATICALLY BE CONSIDERED INCOMPLETE IF IT IS NOT COMPLETED): Is any part of the land on which the facility is located (including treatment units, discharge conveyances, stormwater holding basins and/or flow equalization basins) owned by a person or entity other than the applicant? ( ) No ( ) Yes – the applicant or applicant’s certifying official must ensure that such landowner(s) have been notified of the applicant’s intent to obtain an OPDES permit and initial the box to the right indicating that such notification has been made. 22. List other information which should be brought to the attention of the Department of Environmental Quality (DEQ) in regard to the issuance of a discharge permit for the facility. Form 2M1 - Page 6 Certification: 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 directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete. I also certify that I will provide for the operation of this facility in accordance with the Oklahoma Discharge Permits and Pollution Control Regulations and will provide certified operators as required by the Oklahoma Water and Wastewater Operators Certification Act. I further certify that I shall acquire or possess a right to the use of the property or properties on which the discharging facilities, activities or discharge sources are located as well as the property on which the proposed discharge point(s) are located, including the access route thereto. I understand I shall maintain such right of use and access for the duration of the permit term. I am aware that there are significant penalties for submitting false information, including revocation of the permit and the possibility of fine and imprisonment for knowing violations. Note: Applications must be signed by the authorized chief elective or executive officer of the applicant, or by the applicant, if an individual. Name (print) ______________________________________________ Title ______________________________________________ Date ______________________________________________ Signature ______________________________________________ Subscribed and sworn to before me this _______________day of____________, 20_____. _________________________________ My commission expires____________________ Notary Public The application shall be filed in duplicate with the original and one copy to be submitted to the DEQ, and one copy to be submitted to the local DEQ office. Please return completed form with attachments to: Water Quality Division Department of Environmental Quality 707 N. Robinson P.O. Box 1677 Oklahoma City, Oklahoma 73101-1677 Form 2M1 - Page 7 TABLE I DESCRIPTION OF INFLUENT AND EFFLUENT Influent Effluent Parameter and Code 214 Annual Average Value (1) Annual Average Value (2) Lowest Monthly Average Value (3) Highest Monthly Average Value (4) Frequency of Analysis (5) No. of Samples (6) Sample Type (7) Flow (millions gallons per day) 50050 pH 00400 N/A N/A Temperature - winter (° F) 74028 Temperature - summer (° F) 74027 Fecal Streptococci Bacteria (number/100 ml) 75054 (Provide if available) Fecal Coliform Bacteria (number/100 ml) 75055 (Provide if available) Total Coliform Bacteria (number/100 ml) 75056 (Provide if available) BOD 5-day (mg/l) 00310 Chemical Oxygen Demand (mg/l) 00340 (Provide if available) OR Total Organic Carbon (mg/l) 00680 (Provide if available) (Either analysis acceptable) Form 2M1 - Page 8 TABLE I (Continued) DESCRIPTION OF INFLUENT AND EFFLUENT Influent Effluent Parameter and Code 214 Annual Average Value (1) Annual Average Value (2) Lowest Monthly Average Value (3) Highest Monthly Average Value (4) Frequency of Analysis (5) No. of Samples (6) Sample Type (7) Chlorine - Total Residual (mg/l) 50060 Total Solids (mg/l) 00500 Total Dissolved Solids (mg/l) 70300 Total Suspended Solids (mg/l) 00530 Settleable Matter (Residue) (mg/l) 00545 Kjedahl Nitrogen (mg/l) 00625 (Provide if available) Nitrate (as N) (mg/l) 00620 (Provide if available) Nitrite (as N) (mg/l) 00620 (Provide if available) Phosphorous, Total (as P) (mg/l) 00665 (Provide if available) Dissolved Oxygen (DO) (mg/l) 00300 N/A Form 2M1 - Page 9 SECTION II INDUSTRIAL WASTEWATER CONTRIBUTION TO MUNICIPAL SYSTEM Submit a description of each industrial facility discharging to the municipal system, using a separate Section II for each. Indicate the 4 digit Standard Industrial Classification (SIC) Code for the industry, the major product or raw material, the flow (in gallons per day), and the characteristics of the wastewater discharged from the industrial facility into the municipal system. 1. Major Contributing Facility Contact person __________________________________________________________________________ Name of facility __________________________________________________________________________ Address ________________________________________________________________________________ City ____________________________ County ________________________________________________ State ___________________________ ZIP Code ____________________ Telephone (_____) ______________ Fax (_____) __________________ Cell Phone (_____) _____________ E-mail Address ___________________________________________________________________________ 2. Product or item produced at this facility _____________________________________________________ 3. Primary Standard Industrial Classification (SIC) Code _________________________________________ 4. Principal Product or Raw Material Product or Raw Material Quantity Units ___________________________ ______________________ _____________________ ___________________________ ______________________ _____________________ ___________________________ ______________________ _____________________ 5. Flow: Indicate the volume of wastewater discharged into the municipal system in gallons per day (gpd) and whether this discharge is intermittent or continuous. ____________________GPD Intermittent ( ) Continuous ( ) 6. Pretreatment Provided: Indicate if pretreatment is provided prior to entering the municipal collection system. Yes ( ) No ( ) 7. Characteristics of Wastewater: Please list the pollutants and maximum concentrations of the pollutants in the table below. Pollutant Maximum Concentration Form 2M1 - Page 10
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Agency | Environmental Quality, Oklahoma Department of |
Agency Code | '292' |
Form Title | Form 2M1 Major Discharge Application for Permit to Discharge Municipal Domestic Wastewater |
Frequency | Irregular |
AgencyDivisionDeptBranch | WQD Water Quality Division |
Form Number | Form 2M1 |
Full Text | Form 2M1 Instructions - Page 1 Return to: Oklahoma Department of 707 N. Robinson Revised June 2008 Environmental Quality P.O. Box 1677 previous editions Water Quality Division Oklahoma City, OK 73101-1677 are obsolete Municipal Permitting Section Oklahoma DEQ Application for Permit to Discharge Municipal/Domestic Wastewater Form 2M1 – Major Discharge PLEASE DETACH THESE INSTRUCTIONS AND RETURN ONLY THE COMPLETED APPLICATION FORM ITSELF. This form must be completed by all major facilities applying for a permit to discharge under DEQ’s Municipal OPDES Permit Program. See instructions for the submittal of applications and the public notice requirements. Form 2M1 Instructions - Page 2 OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY INSTRUCTIONS - DEQ FORM 2M1 (major) APPLICATION FOR PERMIT TO DISCHARGE MUNICIPAL/DOMESTIC WASTEWATER Form 2M1 must be completed by the owner/responsible official of a major municipal/domestic wastewater facility that wishes to discharge pollutants to waters of the State of Oklahoma. A major municipal/domestic wastewater facility is defined as a facility that discharges one million gallons per day (mgd) or greater. Please read the instructions below while completing Form 2M1 and respond to each item. The Oklahoma Department of Environmental Quality (DEQ) cannot evaluate an application until it is complete. If a particular item does not apply to the facility for which the application is being prepared, or if the correct answer is "NA" (for not applicable) indicate this on the application. If you have questions about any of the items, please contact DEQ or your local DEQ office for assistance. DO NOT attempt to complete the application form before reading these instructions. NOTE: DO NOT write in box marked " FOR DEQ USE ONLY". SECTION I 1. Give the legal name of the town, city, public entity or name of the person (if privately owned) legally responsible for operating and maintaining the facility. 2. Give the street address, P.O. Box, city, county, state, zip code, telephone number fax number, and e-mail address if applicable of the main office for the applicant in Item 1. This may or may not be the same location of the facility. 3. Give the name of the facility, the street address, telephone number fax number, and e-mail address if applicable and if it is different from the address in Items 1 and 2. 4. Give the physical location of the facility – longitude/latitude and legal description to a 10 acre tract, 1/4,1/4,1/4, Section, Township and Range. Note: This is the location of the treatment plant and it is not necessarily the same as the point of discharge. 5. Indicate whether this is a Public, Private, Federal or State owned facility. 6. Give the name, title, address, and telephone number, cell phone number, fax number, and e-mail address of a person who is familiar with the facility and information in the application and who may be contacted concerning the application. Form 2M1 Instructions - Page 3 7. Indicate whether the discharge is wastewater from a lagoon system, mechanical plant or, if other, explain. 8. Below is a list of definitions of the types of treatment listed in Item #8. Check more than one item if needed. Lagoon systems: A. Total Retention by Evaporation - Wastewater goes to a lagoon or series of lagoons which have no outlet or any other way to discharge. Lagoons cannot be classified total retention if they have any kind of operable outlet structure, even if it is not used. See DEQ Form 530E for Total Retention Facilities. B. Land Application - Wastewater is given preliminary treatment then applied to land (example: irrigation) in such a manner to insure that no runoff enters surface waters. C. Discharge to Receiving Water - Wastewater goes to a lagoon or series of lagoons and then to a receiving water through a designed outlet structure. Check this box even if the outlet structure is not being used. Mechanical Treatment Plants - Please name and describe the mechanical treatment process used at your facility. (Examples: trickling filter, activated sludge, extended air, sequential batch reactor, oxidation ditch) Other - Please name and explain any process used at your facility other than those listed above. 9. If the facility uses chlorine or any other halogen, indicate whether the facility dechlorinates or dehalogenates before discharging to a receiving water. If chlorine or any other halogen is used as a disinfecting agent to meet bacteria limits, or for other purposes, a residual limit of no-measurable value will be included in the permit. Dechlorination or dehalogenation will be necessary to meet the limit. Please indicate whether dechlorination or dehalogenation is provided at your facility. 10. Design flow is established when the construction permit is approved. Design Flow: the quantity of wastewater in million gallons per day (mgd) the facility was designed to treat in one day. List up to 3 decimal places. Example: 3.120 = 3 million one hundred twenty thousand gallons per day. 11. Enter the number for each discharge point and the average quantity of treated wastewater discharged each day from each pipe. 12. Name the body of surface water that receives treated wastewater. If the receiving stream does not have a name, please indicate what named creek or river downstream receives the tributary flow, and fill out as "tributary of ________ Creek Form 2M1 Instructions - Page 4 or River." Check the item which indicates the frequency of wastewater discharges. continuous: discharging without interruption batch: discharging several times during the day (i.e. from a sequential batch reactor facility intermittent: sporadic discharges during the year seasonal: discharging only during certain periods during the year Give the location of the point of discharge to the receiving water. This may be different than the location of the facility. In giving the legal description, provide both the latitude-longitude and 1/4, 1/4, 1/4, Section, Township and Range. Attach addition sheets if necessary to describe additional outfalls. 13. Indicate whether the higher influent flow caused by heavy rains is diverted and discharged resulting in a bypass of partially or completely treated wastewater or if it is stored for later treatment (as in a holding basin). 14. Number 14. A through B of the application concerns the treatment and disposal of biosolids/sludge. A. Common biosolids/sludge treatment processes are aeration, lime stabilization, heat stabilization etc. B 1. Sludge management plan numbers start with SMP and usually have 7 numbers. In giving the land application sites, provide the legal description 1/4, 1/4, 1/4, Section, Township and Range and County. Attach additional sheet if facility has more than 3 sites. B 2. The permittee shall be certain that all landfills used for sewage sludge disposal comply with the state and federal regulations for landfills and solid waste disposal. 15. State if any industries in the community discharge industrial wastewater to the sewer system. If the answer to this question is yes, submit Section II of the application form for each significant industrial facility. Identify any industrial facilities that are “Categorical”. Categorical industries are listed at 40 CFR 122 Appendix A - NPDES Primary Industry Categories (See Attachment 1, page 6). Indicate what type of controls are in place to deal with industrial discharges to the treatment system. 16. Maps and Drawings - A schematic of wastewater flow through the facility and a location map of the facility are required. All sheets should be letter size with margins for filing and binding and on paper suitable for reproduction. Discharge points should be identified with discharge serial numbers. All sheets must include the applicant's name, facility location and date of drawing. Form 2M1 Instructions - Page 5 17. Any information, laboratory analysis, concerning the pollutants in Table 1 should be entered in the table or results attached to the application. 18. Attachments 2 and 3 (Pages 6 through 10) are enclosed for your convenience. Attachment 2 is 40 CFR 122 Appendix D listing all the priority pollutants (Tables I, II, III, IV and V). Attachment 3 lists the approved test methods for analyses of wastewater and associated minimum quantification levels as required. 19. Table V, of 40 CFR 122, Appendix D is reproduced in attachment 2 (Page 7) of these instructions 20. The results for any and all analysis of pollutants for the previous three years should be put in a table and attached to the application. 21. If the answer to this question is yes a landowner notification form (found at http://www.deq.state.ok.us/ ) must be sent to the landowner and the applicant’s certifying official must initial the box certifying that this has been done. 22. All other information regarding the facility having to do with the environmental/operational permits including maps, process diagrams, or chemical analysis should be included with the permit application. SECTION II 1. Give the name, title, address, and telephone number, cell phone number, fax number, and e-mail address of a person who is familiar with the industrial facility and information in the application and who may be contacted concerning the application. 2. All products and by-products for this facility should be listed. 3. Identify any industrial facilities that are “Categorical”. Categorical industries are listed at 40 CFR 122 Appendix A - NPDES Primary Industry Categories (See Attachment 1, page 6). The SIC codes can be found in or should be obtained from the contact described above. 4. Please specify the product produced or raw materials used to produce the final product, how many are produced, and the unit of measurement in which the final product or raw materials are measured. 5. Indicate the volume of wastewater discharged into the municipal system in gallons per day and check the item which indicates the frequency of wastewater discharges. continuous: discharging without interruption Form 2M1 Instructions - Page 6 intermittent: sporadic discharges during the year 6. Indicate if the industrial facility pretreats its wastewater prior to entering the municipal collection system. 7. List the pollutants and maximum concentrations of the pollutants in the industrial facilities wastewater. The information provided in the application will be considered in the evaluation and processing of a discharge permit for the referenced facility. Be advised that test procedures used in the analyses of influents, effluents and sludge, must conform to approved EPA methodology or it will not be accepted for the discharge permit evaluation. Please note that the application must be signed by the authorized chief elective or executive officer of the applicant, or by the applicant if an individual. The authorized signature must be notarized. An example of a common mistake is when a Public Works Authority Chairman signs the application as - John Doe, Mayor. The Mayor is not the legal official of the PWA, the chairman is, even if the individual holds both positions. Please read the certification carefully. There are significant penalties for submitting false information on this application form. Form 2M1 may be separated from the instruction before mailing. NOTICE FOR ALL APPLICANTS Upon filing an application for a new permit, renewal of an existing permit, or major modification of an existing permit with the Department, the applicant shall publish a notice of the filing in a local newspaper which contains: (1) Date of filing; (2) Name and address of the applicant; (3) Type of wastewater discharge and permit sought; (4) Location, including legal description and street address of facility and discharging point or points; (5) Name of receiving water; (6) Name, address and telephone number of contact person for applicant; and (7) Locations where application may be reviewed. Form 2M1 Instructions - Page 7 Attachment 1 40 CFR Ch. 1 Pt. 122 APPENDIX A-NPDES Primary INDUSTRY CATEGORIES Any permit issued after June 30, 1981 to dischargers in the following categories shall include effluent limitations and a compliance schedule to meet the requirements of section 301(b)(2)(A),(C),(D),(E), and (F) of CWA, whether or not applicable effluent limitations guidelines have been promulgated See §§ 122.44 and 122.46. Industry Category Adhesives and sealants Aluminum forming Auto and other laundries Battery manufacturing Coal mining Coil coating Copper forming Electrical and electronic components Electroplating Explosives manufacturing Foundries Gum and wood chemicals Inorganic chemicals manufacturing Iron and steel manufacturing Leather tanning and finishing Mechanical products manufacturing Ore mining Organic chemicals manufacturing Paint and ink formulation Pesticides Petroleum refining Pharmaceutical preparations Photographic equipment and supplies Plastics processing Plastic and synthetic materials manufacturing Porcelain enameling Printing and Publishing Pulp and paper mills Rubber processing Soap and detergent manufacturing Steam electric power plants Textile mills Timber products processing 40CFR 261.20 Subpart C-Characteristics of Hazardous Waste § 261.20 General (a) A solid waste, as defined in § 261.2, which is not excluded from regulation as a hazardous waste under § 261.4(b), is a hazardous waste if it exhibits any of the characteristics identified in this subpart. {Comment: § 262.11 of this chapter sets forth the generator’s responsibility to determine whether his waste exhibits one or more of the characteristics identified in this subpart} (b) A hazardous waste which is identified by a characteristic in this subpart is assigned every EPA Hazardous Waste Number that is applicable as set forth in this subpart. This number must be in compliance with the notification requirements of section 3010 of the Act and all applicable recordkeeping and reporting requirements under parts 262 through 265, 268, and 270 of this chapter. (c) For purposes of this subpart, the Administrator will consider a sample obtained using any of the applicable sampling methods specified in Appendix I to be a representative sample within the meaning of Part 260 of this chapter. {Comment: Since the Appendix I sampling methods are not being formally adopted by the Administrator, a person who desires to employ an alternative sampling method is not required to demonstrate the equivalency of his method under the procedures set forth in §§ 260.20 and 260.21.} {45FR 33119.May 1980. As amended at 51 FR 40636. Nov. 7, 1986: 55 FR 22684. June 1, 1990} Form 2M1 Instructions - Page 8 Attachment 2 Appendix D to Part 122 – NPDES Permit Application Testing Requirements (§ 122.21) 15B butylbenzyl phthalate Bryllium, Total Carbofuran Table II - Organic Toxic Pollutants 16B 2 chloronaphthalene Cadmium, Total Carbon disulfide In Each Of Four Fractions In 17B 4 chlorophenyl phenyl ether Chromium, Total Chloropyrifos Analysis By Gas Chromatogra- 18B chrysene Copper, Total Coumaphos phy/Mass Spectroscopy (GS/MS) 19B dibenzo(a,h)anthracene Lead, Total Cresol Volatiles 20B 1,2 dichlorobenzene Mercury, Total Crotonaldehyde IV acrolein 21B 1,3 dichlorobenzene Nickel, Total Cyclohexane 2V acrylonitrile 22B 1,4 dichlorobenzene Selenium, Total 2,4-D (2,4-Dichlorophenoxy acetic acid) 3V benzene 23B 3,3 dichlorobenzidine Silver, Total Diazinon 5V bromoform 24B diethyl phthalate Thallium, Total Dicamba 6V carbon tetrachloride 25B dimethyl phthalate Zinc, Total Dichlobenil 7V chlorobenzene 26B di-n-butyl phthalate Cyanide, Total Dichlone 8V chlorodibromomethane 27B 2,4 dinitrotoluene Phenols, Total 2,2-Dichloropropionic acid 9V chloroethane 28B 2,6 dinitrotoluene Dichlorvos 10V 2-chloroethylviny ether 29B di-n-octyl phthalate Table IV-Conventional and Noncon- Diethyl amine 11V chloroform 30B 1,2-diphenylhydrazine(as azobenzene) ventional Pollutants Required Dimethyl amine 12V dichlorobromomethane 31B fluroranthene to be tested by existing Dis- Dintrobenzene 14V 1,1 dichloroethane 32B fluorene chargers if expected to be present Diquat 15V 1,2 dichloroethane 33B hexachlorobenzene Disulfoton 16V 1,1 dichloroethylene 34B hexachlorobutadiene Bromide Diuron 17V 1,2 dichloropropane 35B hexachlorocyclopentadiene Chlorine, Total Residual Epichlorohydrin 18V 1,3 dichloropropylene 36B hexachloroethane Color Ethion 19V ethylbenzene 37B indeno(1,2,3-cd)pyrene Fecal Colliform Ethylene diamine 20V methyl bromide 38B isophorone Fluoride Ethylene dibromide 21V methyl chloride 39B napthalene Nitrate-Nitrite Formaldehyde 22V methylene chloride 40B nitrobenzene Nitrogen, Total Organic Furfural 23V 1,1,2,2 tetrachloroethane 41B N-nitrosodinethylamine Oil and Grease Guthion 24V tetrachloroethylene 42B N-nitrosodi-n-propylamine Phosphorus, Total Isoprene 25V toluene 43B N-nitrosodiphenylamine Radioactivity Isopropanolamine Dodecylbenzenesulfonate 26V 1,2-trans-dichloroethylene 44B phenanthrene Sulfate Kelthane 27V 1,1,1 trichloroethane 45B pyrene Sulfide Kepone 28V 1,1,2 trichloroethane 46B 1,2,4 trichlorobenzene Sulfitee Malathion 29V trichloroethylene Pesticides Surfactants Mercaptodimethur 31V vinyl chloride 1P aldrine Aluminum, Total Methoxychior Acid Compounds 2P alpha-BHC Barlum, Total Methyl mercaptan 1A 2 chlorophenol 3P beta-BHC Boron, Total Methyl methacrylate 2A 2,4 dichlorophenol 4P gamma-BHC Cobalt, Total Methyl parathion 3A 2,4 dimethylphenol 5P delta/BHC Iron, Total Mevinphos 4A 4,6 dinitro-o-cresol 6P chlordane Magnesium, Total Mexacarbate 5A 2,4 dinitrophenol 7P 4,4 DDT Molybdenum, Total Monoethyl amine 6A 2 nitrophenol 8P 4,4 DDE Manganese, Total Monomethyl amine 7A 4 nitrophenol 9P 4,4 DDD Tin, Total Naled 8A p-chloro-m-cresol 10P dieldrin Titanium, Total Mapthenic acid 9A pntachlorophenol 11P alpha-endosulfan Nitrotoluene 10A phenol 12P beta-endosulfan Table V-Toxic Pollutants and Haz- Parathion 11A 2,4,6 trichlorophenol 13P endosulfan sulfate ardous Subtances Required To Phenolsulfanate Base/Neutral 14P endrin Be Identified By Existing Dis- Phosgene 1B acenaphthene 15P endrin aldehide chargers if expected to be present Propargite 2B acenaphthylene 16P heptachlor Propylene oxide 3B anthracene 17P heptachlor epoxide Toxic Pollutants Pyrethrins 4B benzidine 18P PCB-1242 Quinoline 5B benzo(a)anthracene 19P PCB-1254 Asbestos Resorcinol 6B benzo(a)pyrene 20P PCB-1221 Hazardous Subtances Strontium 7B 3,4 benzofluoranthene 21P PCB-1232 Acetaldehyde Strychnine 8B benzo(ghi)perylene 22P PCB-1248 Allyl alcohol Styrene 9B benzo(k)fluoranthene 23P PCB-1260 Allyl chloride 2,4,5-T (2,4,5-Trichlorophenoxy acetic acid) 10B bis(2-chloroethoxy)methane 24P PCB-1016 Amyl acetate TDE (Tetrachlorodiphenylethane) 11B bis(2-chloroethyl)ether 25P toxaphene Anlline 2,4,5-TP {2(2,4,5-Trichlorophenoxy) propa- 12B bis(2-chloroisopropyl)ether Benzonitrile noci acid} 13B bis(2-ethylhexyl)phthalate Table III-Other Toxic Pollutants Benzyl chloride Trichlorofan 14B 4 bromophenyl phenyl ether (Metals and Cyanide) and Total Butyl chloride Triethanolamine dodecylbenzenesulfonate Phenols Butyl acetate Triethylamine Butylamine Trimethylamine Antimony, Total Captan Uranium Arsenic, Total Carbaryl Vanadium Vinyl Acetate Xylene Xylenol Zirconium Form 2M1 Instructions - Page 9 ATTACHMENT 3 MINIMUM QUANTIFICATION LEVELS (MQLs) REQUIRED MQL METALS AND CYANIDE (ug/L) EPA METHOD Antimony (Total)1 60 200.7 Arsenic (Total)1 10 206.5 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Beryllium (Total)1 5 200.7 Cadmium (Total) 1 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Chromium (Total)1 10 200.7 Chromium (3+)1 10 200.7 Chromium (6+)1 10 200.7 Copper (Total) 10 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Lead (Total) 5 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Mercury (Total)1 0.2 245.1 revision 3.0 (1994) Molybdenum (Total) 30 200.7 Nickel (Total)1 (Freshwater) 40 200.7 Nickel (Total) (Marine) 5 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Selenium (Total)1 5 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Silver (Total) 2 200.7 revision 4.4 (1994) 200.8 revision 5.4 (1994) 200.9 revision 2.2 (1994) Thallium (Total)1 10 279.2 revision Zinc (Total)1 20 200.7 Cyanide (Total)1 10 335.4 DIOXIN 2,3,7,8-Tetrachloro-dibenzo- p-dioxin (TCDD)2 0.00001 1613 VOLATILE COMPOUNDS Acrolein3 50 624 Acrylonitrile3 50 624 Benzene3 10 624 Bromoform4 10 624 Carbon Tetrachloride4 10 624 Chlorobenzene4 50 624 Chlorodibromomethane4 10 624 Chloroethane 50 624 2-Chloroethylvinyl Ether3 10 624 Chloroform4 10 624 Dichlorobromomethane4 10 624 1,1-Dichloroethane4 10 624 1,2-Dichloroethane4 10 624 1,1-Dichloroethylene4 10 624 1,2-Dichloropropane4 10 624 1,3-Dichloropropylene4 10 624 Form 2M1 Instructions - Page 10 Ethylbenzene4 10 624 Methyl Bromide (Bromomethane) 50 624 Methyl Chloride (Chloromethane) 50 624 Methylene Chloride4 20 624 1,1,2,2-Tetrachloroethane4 10 624 Tetrachloroethylene4 10 624 Toluene4 10 624 1,2-Trans-Dichloroethylene4 10 624 1,1,1-Trichloroethane4 10 624 1,1,2-Trichloroethane4 10 624 Trichloroethylene4 10 624 Vinyl Chloride4 10 624 ACID COMPOUNDS 2-Chlorophenol4 10 625 2,4-Dichlorophenol4 10 625 2,4-Dimethylphenol1 10 625 4,6-Dinitro-o-Cresol1 (12 methyl 4,6-dinitrophenol)4 50 625 2,4-Dinitrophenol4 50 625 2-Nitrophenol4 20 625 4-Nitrophenol4 50 625 p-Chloro-m-Cresol (4 chloro-3-methylphenol)1 10 625 Pentachlorophenol4 50 625 Phenol4 10 625 2,4,6-Trichlorophenol4 10 625 BASE/NEUTRAL COMPOUNDS Acenaphthene4 10 625 Acenaphthylene4 10 625 Anthracene4 10 625 Benzidine3 50 625 Benzo (a) Anthracene4 10 625 Benzo (a) Pyrene4 10 625 3,4-Benzofluranthene4 10 625 Benzo (ghi) Perylene 20 625 Benzo (k) Fluranthene4 10 625 Bis (2-Chloroethoxy) Methane4 10 625 Bis (2-Chloroethyl) Ether4 10 625 Bis (2-Chloroisopropyl) Ether4 10 625 Bis (2-Ethylhexyl) Phthalate4 10 625 4-Bromophenyl Phenyl Ether4 10 625 Butylbenzyl Phthalate4 10 625 2-Chloronapthalene4 10 625 4-Chlorophenyl Phenyl Ether4 10 625 Chrysene4 10 625 Dibenzo (a,h) Anthracene4 20 625 1,2-Dichlorobenzene4 10 625 1,3-Dichlorobenzene4 10 625 1,4-Dichlorobenzene4 10 625 3,3’-Dichlorobenzidine 50 625 Diethyl Phthalate4 10 625 Dimethyl Phthalate4 10 625 Di-n-Butyl Phthalate4 10 625 2,4-Dinitrotoluene4 10 625 2,6-Dinitrotoluene4 10 625 Di-n-octyl Phthlate4 10 625 1,2-Diphenylhydrazine3 20 625 Fluoranthene4 10 625 Form 2M1 Instructions - Page 11 Fluorene4 10 625 Hexachlorobenzene4 10 625 Hexachlorobutadiene4 10 625 Hexachlorocyclopentadiene4 10 625 Hexachloroethane 20 625 Indeno (1,2,3-cd) Pyrene 20 625 (2,3-o-phenylene pyrane) Isophorone4 10 625 Naphthalene4 10 625 Nitrobenzene4 10 625 N-nitrosodimethvlamine 50 625 N-nitrosodi-n-propylamine 20 625 N-nitrosodiphenylamine 20 625 Phenanthrane4 10 625 Pyrene4 10 625 1,2,4-Tricfhlorobenzene4 10 625 PESTICIDES Aldrin1 0.05 608 Alpha-BHC1 0.05 608 Beta-BHC1 0.05 608 Gamma-BHC (Lindane)1 0.05 608 Delta-BHC1 0.05 608 Chlordane1 0.2 608 4,4’-DDT1 0.1 608 4,4’-DDE (p,p-DDX)1 0.1 608 4,4’-DDD (p,p-TDE)1 0.1 608 Dieldrin1 0.1 608 Alpha-endosulfan1 0.1 608 Beta-endosulfan1 0.1 608 Endosulfan sulfate1 0.1 608 Endrin1 0.1 608 Endrin aldehyde1 0.1 608 Heptachlor1 0.05 608 Heptachlor epoxide1 0.1 608 (BHC-hexachlorocyclohexane) PCB-12421 1.0 608 PCB-1254 1.0 608 PCB-1221 1.0 608 PCB-1232 1.0 608 PCB-1248 1.0 608 PCB-1260 1.0 608 PCB-1016 1.0 608 Toxaphene1 5.0 608 1 Based on Contract Required Quantitation Level (CRQL) developed 2 Dioxin National Strategy 3 No CRQL established 4 CRQL basis, equivalent to MQL MQL based on 3.3 times Level of Detection (LOD) in 40 CFR 136, Appendix B Form 2M1 - Page 1 OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY APPLICATION FOR PERMIT TO DISCHARGE MUNICIPAL/DOMESTIC WASTEWATER UNDER THE OKLAHOMA POLLUTANT DISCHARGE ELIMINATION SYSTEM (OPDES) FORM 2M1 (major) FOR DEQ USE ONLY Application/Permit Number OK00____________________ Facility ID No. _________________ Date Received: ____________________________________ SIC Code: _________________________________________ If a proposed facility, give estimated date of completion: _________________________ DEQ PERMIT ENGINEER: ____________________________ DO NOT attempt to complete this application without reading the instructions! SECTION I 1. Legal name of applicant: ___________________________________________________________________________________________________ 2. Mailing address of applicant: Street Address or PO Box ______________________________________________________________________________ City _______________________ County __________________ State ___________________ Zip Code ________________ Telephone (____)_______________________________ Fax (_____)____________________________________________ E-mail Address ______________________________________________________________________________________ 3. Name and address of facility: Facility Name________________________________________________________________________________________ Street Address _______________________________________________________________________________________ City ________________________ County _________________ State ___________ Zip Code________________________ Telephone (____)_______________________________ Fax (_____)____________________________________________ E-mail Address ______________________________________________________________________________________ 4. Location of discharging facility (e.g., NE ¼ , SW ¼ , SE ¼ , Section 1, Township 2 North, Range 3 West): Legal Description of Facility Location ______ __, ______ __, _____ __, Section ______, Township _____, Range ________ Latitude: _______________N Longitude: _______________W 5. Type Ownership: Public ( ) Private ( ) Federal ( ) State ( ) 6. Contact Person: Name and Title _______________________________________________________________________________________ Address ____________________________________________________________ City _____________________________ County _________________ State ______________ Zip Code _____________ Telephone (_____) ____________________ Fax (_____) ____________________ Cell Phone (_____) ____________________ E-mail Address _______________________________________________________________________________________ Form 2M1 - Page 2 7. Type of discharge: ______ A. Wastewater from lagoon system ______ B. Wastewater from mechanical plant ______ C. Other (specify) ____________________________________________________________________________ 8. Type of treatment: ________ A. Lagoon system with total retention by evaporation (Does not require this form, it requires Form 583-B) ________ B. Lagoon system with effluent used for land application (Does not require this form, it requires Form 852-NIWP) ________ C. Lagoon system with effluent discharge to receiving water ________ D. Lagoon system with effluent discharge and effluent used for land application ________ E. Mechanical Plant: (please describe briefly) _____________________________________________________ ___________________________________________________________________________________________________ 9. Is chlorine or any other halogen used at this facility? ( ) Yes ( ) No If yes, is dechlorination or dehalogenation used at this facility? (See instructions) ( ) Yes ( ) No Is an ultraviolet (UV) system used at this facility? ( ) Yes ( ) No 10. Design flow of facility in million gallons per day (mgd) ____________________________________________________ 11. Discharge point number Total volume presently discharged (List all outfalls) million gallons per day (mgd) 001 ________________ 002 (if applicable) ________________ 003 (if applicable) ________________ 12. Legal description(s) of all discharge point(s): Outfall 001: Name of receiving water(s): ___________________________________________________________________________ Discharge is (check one) Continuous ( ) Intermittent ( ) Seasonal ( ) Latitude: _______________N Longitude: _______________W Legal Description of discharge point ______ __, ______ __, _____ __, Section ______, Township _____, Range ________ Outfall 002 (if applicable): Name of receiving water(s): ___________________________________________________________________________ Discharge is (check one) Continuous ( ) Intermittent ( ) Seasonal ( ) Latitude: _______________N Longitude: _______________W Legal Description of discharge point ______ __, ______ __, _____ __, Section ______, Township _____, Range ________ Form 2M1 - Page 3 Outfall 003 (if applicable): Name of receiving water(s): ___________________________________________________________________________ Discharge is (check one) Continuous ( ) Intermittent ( ) Seasonal ( ) Latitude: _______________N Longitude: _______________W Legal Description of discharge point ______ __, ______ __, _____ __, Section ______, Township _____, Range ________ 13. During periods of heavy rain, is the increased flow: ( ) Bypassed to the receiving stream with no treatment ( ) Given partial treatment and discharged ( ) Given complete treatment and discharged ( ) Stored for later treatment 14. Biosolids/Sludge generated by this facility: A. Current biosolids/sludge treatment process. (Please explain) ___________________________________________________________________________________________ ___________________________________________________________________________________________ B. Amount of biosolids/sludge produced (dry metric tons/year)____________________________________________ 1. Land application of biosolids Sludge management plan, if any: Sludge management permit number ___________________ approved by the Department of Environmental Quality or the Oklahoma State Department of Health on ___________________ Location(s) of current land application site(s) (legal description to the nearest 10 acres). Site 1: ______, ______, _____, Section ______, Township _____, Range _______ County ________ Site 2 (if applicable): ______, ______, _____, Section ______, Township _____, Range _______ County _______ Site 3 (if applicable): ______, ______, _____, Section ______, Township _____, Range _______ County ________ 2. Landfilled sludge Sludge disposition plan, if any: Sludge disposition permit number (if applicable) ___________________ approved by the Department of Environmental Quality or the Oklahoma State Department of Health on ___________________ Name of Landfill ___________________________________________________________________________ Landfill permit number ______________________________________________________________________ 15. Does this facility receive industrial wastewater? Yes ( ) No ( ) If "Yes", Submit Section II of this form (attached) for each significant industrial facility discharging to the sewer system. Are industrial discharge(s) to the system(s) controlled by Form 2M1 - Page 4 ( ) Ordinance ( ) Pretreatment Program Form 2M1 - Page 5 16. Maps and drawings - Attach all required maps and drawings to the back of this application. (see instructions) 17. Complete attached Table 1 detailing both influent and effluent pollutants. 18. Submit test results of a composite sample of effluent, or when appropriate grab samples, for all pollutants listed in 40 CFR 122, Appendix D, Table II and Table III. 19. Submit quantitative data on pollutants listed in 40 CFR 122, Appendix D, Table V that are known or reasonably expected to be discharged. 20. Tabulations of all results collected pertaining to the quality and quantity of all toxic pollutants identified as a constituent in the publicly owned treatment works (POTW) effluent and regulated or prohibited by an Industrial Waste Ordinance during the period from three years prior to the date of this application to the present. 21. Landowner Notification (THIS SECTION MUST BE COMPLETED PRIOR TO SUBMISSION OF THE APPLICATION – THE APPLICATION WILL AUTOMATICALLY BE CONSIDERED INCOMPLETE IF IT IS NOT COMPLETED): Is any part of the land on which the facility is located (including treatment units, discharge conveyances, stormwater holding basins and/or flow equalization basins) owned by a person or entity other than the applicant? ( ) No ( ) Yes – the applicant or applicant’s certifying official must ensure that such landowner(s) have been notified of the applicant’s intent to obtain an OPDES permit and initial the box to the right indicating that such notification has been made. 22. List other information which should be brought to the attention of the Department of Environmental Quality (DEQ) in regard to the issuance of a discharge permit for the facility. Form 2M1 - Page 6 Certification: 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 directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate and complete. I also certify that I will provide for the operation of this facility in accordance with the Oklahoma Discharge Permits and Pollution Control Regulations and will provide certified operators as required by the Oklahoma Water and Wastewater Operators Certification Act. I further certify that I shall acquire or possess a right to the use of the property or properties on which the discharging facilities, activities or discharge sources are located as well as the property on which the proposed discharge point(s) are located, including the access route thereto. I understand I shall maintain such right of use and access for the duration of the permit term. I am aware that there are significant penalties for submitting false information, including revocation of the permit and the possibility of fine and imprisonment for knowing violations. Note: Applications must be signed by the authorized chief elective or executive officer of the applicant, or by the applicant, if an individual. Name (print) ______________________________________________ Title ______________________________________________ Date ______________________________________________ Signature ______________________________________________ Subscribed and sworn to before me this _______________day of____________, 20_____. _________________________________ My commission expires____________________ Notary Public The application shall be filed in duplicate with the original and one copy to be submitted to the DEQ, and one copy to be submitted to the local DEQ office. Please return completed form with attachments to: Water Quality Division Department of Environmental Quality 707 N. Robinson P.O. Box 1677 Oklahoma City, Oklahoma 73101-1677 Form 2M1 - Page 7 TABLE I DESCRIPTION OF INFLUENT AND EFFLUENT Influent Effluent Parameter and Code 214 Annual Average Value (1) Annual Average Value (2) Lowest Monthly Average Value (3) Highest Monthly Average Value (4) Frequency of Analysis (5) No. of Samples (6) Sample Type (7) Flow (millions gallons per day) 50050 pH 00400 N/A N/A Temperature - winter (° F) 74028 Temperature - summer (° F) 74027 Fecal Streptococci Bacteria (number/100 ml) 75054 (Provide if available) Fecal Coliform Bacteria (number/100 ml) 75055 (Provide if available) Total Coliform Bacteria (number/100 ml) 75056 (Provide if available) BOD 5-day (mg/l) 00310 Chemical Oxygen Demand (mg/l) 00340 (Provide if available) OR Total Organic Carbon (mg/l) 00680 (Provide if available) (Either analysis acceptable) Form 2M1 - Page 8 TABLE I (Continued) DESCRIPTION OF INFLUENT AND EFFLUENT Influent Effluent Parameter and Code 214 Annual Average Value (1) Annual Average Value (2) Lowest Monthly Average Value (3) Highest Monthly Average Value (4) Frequency of Analysis (5) No. of Samples (6) Sample Type (7) Chlorine - Total Residual (mg/l) 50060 Total Solids (mg/l) 00500 Total Dissolved Solids (mg/l) 70300 Total Suspended Solids (mg/l) 00530 Settleable Matter (Residue) (mg/l) 00545 Kjedahl Nitrogen (mg/l) 00625 (Provide if available) Nitrate (as N) (mg/l) 00620 (Provide if available) Nitrite (as N) (mg/l) 00620 (Provide if available) Phosphorous, Total (as P) (mg/l) 00665 (Provide if available) Dissolved Oxygen (DO) (mg/l) 00300 N/A Form 2M1 - Page 9 SECTION II INDUSTRIAL WASTEWATER CONTRIBUTION TO MUNICIPAL SYSTEM Submit a description of each industrial facility discharging to the municipal system, using a separate Section II for each. Indicate the 4 digit Standard Industrial Classification (SIC) Code for the industry, the major product or raw material, the flow (in gallons per day), and the characteristics of the wastewater discharged from the industrial facility into the municipal system. 1. Major Contributing Facility Contact person __________________________________________________________________________ Name of facility __________________________________________________________________________ Address ________________________________________________________________________________ City ____________________________ County ________________________________________________ State ___________________________ ZIP Code ____________________ Telephone (_____) ______________ Fax (_____) __________________ Cell Phone (_____) _____________ E-mail Address ___________________________________________________________________________ 2. Product or item produced at this facility _____________________________________________________ 3. Primary Standard Industrial Classification (SIC) Code _________________________________________ 4. Principal Product or Raw Material Product or Raw Material Quantity Units ___________________________ ______________________ _____________________ ___________________________ ______________________ _____________________ ___________________________ ______________________ _____________________ 5. Flow: Indicate the volume of wastewater discharged into the municipal system in gallons per day (gpd) and whether this discharge is intermittent or continuous. ____________________GPD Intermittent ( ) Continuous ( ) 6. Pretreatment Provided: Indicate if pretreatment is provided prior to entering the municipal collection system. Yes ( ) No ( ) 7. Characteristics of Wastewater: Please list the pollutants and maximum concentrations of the pollutants in the table below. Pollutant Maximum Concentration Form 2M1 - Page 10 |
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