2501appl. - updated

For DEQ Use Only		Application for 2501 WPCF General Permit Industrial Reuse Water		For DEQ Use Only

	Date Permit Issued				Date

	File No.		State of Oregon Department of Environmental Quality 811 SW 6th Avenue, Portland, OR 97204		Amount Received

					Check No.

Applicants must provide all the requested information. DEQ will return incomplete or unsigned applications.

A. APPLICANT INFORMATION
1.	Legal name of applicant:
2.	Is the applicant the owner of the facility/property? [ ] Yes [ ] No
3.	Legal status of applicant: [ ] Federal [ ] State [ ] Public [ ] Private [ ] Other (specify):
4.	Name of facility (if different than legal name):
5.	[ ] Facility SIC Code: [ ] or NAICS code:

B. FACILITY LOCATION
1.	Physical street address:
	City: State: Postal Code: County:
2.	Latitude (decimal degrees):	3.	Township: Section:
	Longitude (decimal degrees):		Range: Tax Lot #:

C. CONTACT INFORMATION
1.	RESPONSIBLE PERSON
	Full Name:
	Email: Telephone: [ ] No email address or do not wish to correspond by email.
	Mailing address:
	City: State: Postal Code: County:
2.	FACILITY CONTACT
	[ ] Same as responsible person Full Name:
	Email: Telephone: [ ] No email address or do not wish to correspond by email.
	Mailing address:
	City: State: Postal Code: County:
3.	INVOICE TO
	[ ] Same as responsible person Full Name:
	Email: Telephone: [ ] No email address or do not wish to correspond by email.
	Mailing address:
	City: State: Postal Code: County:

D. INDUSTIAL REUSE WATER SYSTEM INFORMATION
1.	SOURCE OF INDUSTRIAL REUSE WATER (At least one box must be checked)
	[ ] Reverse osmosis concentrate [ ] Water treatment filter backwash [ ] Boiler Blowdown [ ] Non-contact cooling water [ ] Water from washing whole fruits and vegetables [ ] Water from external building washing without use of detergents or chemicals [ ] Water from washing of concrete without use of detergents or chemicals where spills or leaks of toxic or hazardous waste has not occurred [ ] Hydrostatic testing water from an existing vessel that previously contained petroleum products [ ] Other. Please specify:
2.	WATER QUALITY (The box below must be checked)
	[ ] Industrial reuse water screening worksheet attached.
3.	BENEFICIAL PURPOSES
	Planned use or uses of industrial reuse water (select all that apply): [ ] Landscape irrigation of golf courses, cemeteries, highway medians, industrial or business campuses [ ] Agricultural irrigation of crops not intended for human ingestion [ ] Water source for non-residential landscape ponds [ ] Rock crushing, aggregate washing, mixing of concrete [ ] Dust control [ ] Non-structural firefighting
4.	Total estimated quantity of industrial reuse water that will be used annually (gallons):
	Estimated daily maximum quantity of industrial reuse water that will be used (gallons per day):
5.	Location of reuse (select all that apply): [ ] on the property on which it was generated. [ ] on another property with the written approval of the property owner.
6.	SYSTEM DESCRIPTION (A brief description is required)
	Briefly describe the reuse system, including but not limited to, any physical treatment methods, water storage, and a brief description of the irrigation system (if applicable).
E. DOCUMENTATION
1.	The following information is included with this permit application (All boxes must be checked): [ ] Signed Land Use Compatibility Statement [ ] Industrial Reuse Water Quality Screening Worksheet [ ] WRD Registration for Groundwater Reuse Exemption (Qualification for Reuse of Industrial or CAFO Effluent)
2.	The following information is complete and available for review on request: [ ] Water reuse plan, which includes: [ ] Nutrient management plan (if required based on reuse water screening worksheet) [ ] Salt management plan (if required based on reuse water screening worksheet) [ ] Irrigation site evaluation

F. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision. 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. I agree to pay all permit fees required by Oregon Administrative rules 340-045, including new application fees to obtain the permit and an annual compliance determination fee invoiced annually by DEQ to maintain the permit.

Signature		Date

DEQ Permit Fees: SEND CHECK OR MONEY ORDER PAYABLE TO DEQ WITH SIGNED APPLICATION.

The total application fee¹ is $954 ($471 new application fee plus $483 first year annual fee).

Send completed application and permit fees to:

DEQ Northwest Region

2020 SW 4th Avenue, Suite 400

Portland, OR 97201-4987

503-229-5263 or 800-452-4011

DEQ Western Region

750 Front Street NE, Suite 120

Salem, OR 97301-1039

503-378-8240 or 800-349-7677

DEQ Eastern Region

700 SE Emigrant Avenue, Suite 330

Pendleton, OR 97801

541-276-4063 or 800-452-4011

Other Agency Requirements

You must comply with all applicable local, state, and federal laws and regulations. All pipes, valves, and other plumbing appurtenances of the reuse water collection system must comply with the requirements of the Oregon Plumbing Specialty Code. The necessary permits must be obtained from the local building authority. DEQ permit fees do not apply towards any permits required by local authorities.

Please answer all questions and submit with the required permit application fees.

AN INCOMPLETE APPLICATION OR APPLICATION WITH INCORRECT FEES

WILL NOT BE PROCESSED.

If the information requested is not applicable, please indicate as such.

A. APPLICANT INFORMATION

1. Enter the legal name of the applicant. The permit will be issued to this entity. This is the person, business, public organization, or other entity that controls the facility described in this application and will be responsible for complying with the conditions of the permit. This must be the legal Oregon name (e.g., Acme Products, Inc.) or the legal representative of the company if it operates under an assumed business name (e.g., John Smith, dba Acme Products, Inc.). The name must be a legal active name registered with the Oregon Department of Commerce, Corporation Division (503-378-4752), unless otherwise exempted by their regulations.

2. Indicate if the applicant is the owner of the facility.

3. Provide the legal status of the applicant. Indicate "public" for a facility solely owned by local government.

4. Enter the common name of the facility or operation if different from the legal name of the applicant.

5. Enter the Standard Industrial Classification (SIC) fours-digit code or North American Industry Classification system (NAICS) for the facility. These codes are used to describe the primary activity at the facility and may be found on fire marshal reports, insurance papers, or tax forms. The NAICS codes replaced the SIC system in 1997, however, it is usually easy to convert between the two systems so either code is acceptable. SIC or NAICS information is also available from the U.S. Census Bureau at 1-888-756-2427 or at http://www.naics.com/search.htm.

B. FACILITY LOCATION

1. Enter the physical location of the facility (street address, not mailing address), including city, state, postal code, and county.

2. Enter the latitude and longitude in decimal degrees of the proposed site. Please get the latitude and longitude information from DEQ's Longitude Latitude Identification (LLID) Application at http://www.deq.state.or.us/WQ/wqlmaps/wqlmapshome.htm. (Using DEQ’s LLID tool is important so that the data uses the correct map projection.) Click on the “Start LLID Application” link located on this page. The display can be changed between “Road Map”, “Satellite Map”, and “Topo Map” using the tabs in the upper right of the application. Zoom into the site and click on the approximate center of the proposed site. A pushpin will be placed on the map and the Latitude and Longitude of the site will be displayed in a box on the screen.

3. Enter the Township, Range, Section and Tax Lot numbers for the regulated site. Tax lot maps are available at http://www.ormap.net and are listed by Township, Range and Section on the website. A specific tax lot map can be obtained by using the website’s Taxmap Explorer or GIS Map Viewer

C. CONTACT INFORMATION

1. Enter the name, email address, telephone number, and mailing address of the Responsible Official. The Responsible Official is the person that receives official correspondence from DEQ, such as renewal notices or notices of noncompliance, and may be contacted if there are questions about this application.

2. Enter the contact information of the Facility Contact if different from the Responsible Official. The Facility Contact is the person located at the facility that has specific knowledge of the facility or operation under permit (e.g., the treatment plant operator), and may be contacted if there are specific questions about this application.

3. Enter contact information for the person responsible for billing purposes if different from the Responsible Official (e.g., "Invoice to: Business Office - Accounts Payable").

D. INDUSTRIAL REUSE WATER SYSTEM INFORMATION

1. Identify the source of industrial reuse water from the list.

2. Attach the industrial reuse screening worksheet. All required information must be provided on the worksheet or the application is considered incomplete.

3. Indicate how reuse water will be reused. Multiple selections may be made.

4. Provide an estimate in gallons on the total quantity of industrial reuse water that will be used annually.

5. Identify where reuse water will be used. Multiple selections may be made.

6. Provide a brief description of the reuse water system, including any methods used for primary treatment.

E. DOCUMENTATION

1. The following information must be submitted with the permit application as appropriate:

a. Signed Land Use Compatibility Statement

b. WRD Registration for Groundwater Reuse Exemption

2. The following information is complete and available to DEQ on request:

a. Water reuse plan

b. Irrigation site evaluation

F. SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE

1. The signature of a legally authorized representative must be provided in order to process this application. See the table below for more information.

a. Corporation: president, secretary, treasurer, vice-president, or any person who performs principal business function; or a manager of one or more facilities that is authorized in accordance to corporate procedure to sign such documents.

b. Partnership: General partner [list of general partners, their addresses, and telephone numbers]

c. Sole Proprietorship: Owner(s) [each owner must sign the application]

d. City, County, State, Federal, or other Public Facility: Principal executive officer or ranking elected official

e. Limited Liability Company: Member [articles of organization]

f. Trusts: Acting trustee [list of trustees, their addresses, and telephone numbers]

APPLYING FOR COVERAGE UNDER THE 2501 WPCF GENERAL PERMIT

How do I obtain coverage under the 2501 General Permit?

1. Complete a 2501 application, including:

a. 2501 permit application. Download the application from http://www.deq.state.or.us/wq/wqpermit/genpermits.htm or obtain in person from a DEQ regional office. Call 503-229-6114 or 800-452-4011 for location of the location of the nearest regional office.

b. Water quality screening worksheet.

c. A signed Land Use Compatibility Statement.

d. The Oregon Water Resources Department (WRD) Registration for Groundwater Reuse Exemption.

2. Submit the complete 2501 application, required documentation, and permit fees to the appropriate DEQ regional office.

3. DEQ will evaluate the application materials and process the application as follows:

a. An incomplete application will be returned to the applicant for completion.

b. If an application is complete but during review of the application materials DEQ determines that additional information is required, DEQ will request additional information from the applicant. If DEQ and the applicant jointly determine that a plan review or site inspection is necessary to grant coverage under the permit, DEQ will bill the applicant the appropriate general permit activity fees found in OAR 340-045-0070, Table H.

c. If the application materials are complete and industrial reuse water quality meets the screening limits, DEQ will send acknowledgment of registration under the permit. Coverage under the permit will be granted without a DEQ inspection; however, the permit applicant is required to have and maintain accurate and current documentation on the system design, operation and maintenance.

Coverage under the 2501 General Permit is granted when the applicant receives written confirmation notification.