APPLICATION INSTRUCTIONS FOR WPCF-1000 PERMIT

Please answer all questions. An incomplete application will not be processed.

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

A.  REFERENCE INFORMATION:

1.  Enter the legal name of the applicant. This must be the legal Oregon corporate name (i.e., Acme Products, Inc.) or the legal representative of the company if the company operates under an assumed business name (i.e., John Smith, dba Acme Products). The name must be a legal, active name registered with the Oregon Department of Commerce, Corporation Division (503) 378-4752, unless otherwise exempted by the Department of Commerce regulations.

2.  Enter the common name of this facility if different than the legal name.

3.  Enter the latitude and longitude of the approximate center of the facility or site in degrees/minutes/seconds. Latitude and longitude can be obtained from United States Geological Survey (USGS) quadrangle or topographic maps, by calling 1(888) ASK-USGS, or by accessing the Microsoft web site at http://mappoint.msn.com/(rfmcblvhcsxcil553lcfrhjo)/ ome.aspx?mapblast=true or the U.S. Census web site at http://www.census.gov/cgi-bin/gazetteer.

Latitude and longitude for a facility in decimal form must be converted to degrees (), minutes ('), and seconds (") for proper entry on the certification form. To convert decimal latitude or longitude degrees/minutes/seconds, follow the steps in the following example.

Example: Convert decimal latitude 45.1234567 to degrees (), minutes ('), and seconds (").

a)  The numbers to the left of the decimal point are the degrees: 45.

b)  To obtain minutes, multiply the first four numbers to the right of the decimal point by 0.006: 1234 x 0.006 = 7.404.

c)  The numbers to the left of the decimal point in the result obtained in (b) are the minutes: 7'.

d)  To obtain seconds, multiply the remaining three numbers to the right of the decimal from the result obtained in (b) by 0.06: 404 x 0.06 = 24.24. Since the numbers to the right of the decimal point are not used, the result is 24'.

e)  The conversion for 45.1234567 = 457' 24".

4.  Enter the name, telephone and fax number of the facility contact; this would be the person to call in case there are any questions about this application.

5.  Enter the physical location of the facility (not mailing address), including city, state.

6.  Enter the mailing address of the facility if different from the physical location.

7.  Enter invoicing information for billing purposes if different from legal name, telephone #, and mailing address.

B.  GENERAL DESCRIPTION OF FACILITY:

Briefly describe the facility. What goes on here. For other than Storm Water, describe the primary wastewater treatment and disposal.

C.  REQUIRED INFORMATION:

Supply the applicable items for the facility. Insure that a location map and a site layout map are provided for all sites.

D.  OTHER PERMITS:

List the other existing permits for this facility with permit numbers.

C.  SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE:

The signature of a legally authorized representative must be provided in order to process this application. See definition.

Definition of Legally Authorized Representative:

Please also provide the information requested in [brackets]

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

•  Partnership — General partner [list of general partners, their addresses and telephone numbers]

•  Sole Proprietorship — Owner(s) [each owner must sign the application]

•  City, County, State, Federal, or other Public Facility — Principal executive officer or ranking elected official

•  Limited Liability Company — Member [articles of organization]

•  Trusts — Acting trustee [list of trustees, their addresses and telephone numbers]

FEE AND APPLICATION SUBMITTAL:

The new permit application fee is $696 ($213 new application fee plus $483 for the first year’s annual compliance fee).

Send this form and fee to the appropriate DEQ regional office:

Make your check payable to the Department of Environmental Quality.