INSTRUCTIONS FOR COMPLETING THIS FORM:

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 name (i.e., Acme Products, Inc.) or the legal representative of the company if it 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, (http://egov.sos.state.or.us/br/pkg_web_name_srch_inq.login), unless otherwise exempted by their regulations. The permit will be issued to the legal name of the applicant.

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

3.  Enter the physical location of the facility (not mailing address), including city, state, and zip code.

4.  Enter the latitude and longitude of the approximate center of the facility or site in degrees/minutes/seconds to the nearest 15 seconds. Latitude and longitude can be obtained from DEQ’s location finder web site at http://deq12.deq.state.or.us/website/findloc/data.asp. To get the longitude and latitude to appear you can also zoom in and re- center until you find the area. You may want to turn off DEQ interests to eliminate the yellow dots and you may want to turn on the Aerial Photos to help you locate the site (note that the aerial photos are over ten years old). The latitude and longitude will be indicated on the left side of the page once you have checked the locate place at the top of the page and clicked on a location.

5.  Indicate County of facility.

6.  Provide the primary Standard Industrial Classification (SIC) Code and Title for the facility that best describes the primary industrial activities performed by your facility under which you are required to obtain permit coverage. Your primary industrial activity includes any activities performed on-site which are (1) identified by the facility’s one SIC code for which the facility is primarily engaged; and (2) included in the narrative descriptions of 40 CFR 122.26(b)(14)(i), (iv), (v), or (vii), and (ix). See Table 1: Sources Covered on page 3 of the permit for a complete list of SIC codes and industrial activities. The SIC Code is a four digit number assigned to different businesses. The SIC Title corresponds to the Code and is a short description of activities that occur at a business. Typically, SIC Codes are used by the fire marshal or insurance companies. They are also used when filing taxes or registering as a corporation with the state. If you do not know your SIC Code and Title, try the OSHA Web Site at http://www.osha.gov/pls/imis/sic_manual.html or contact DEQ or Agent office for assistance.

7.  If your site has secondary industrial activities (i.e., co-located activities) that are not identified as your primary industrial activity, provide the SIC code(s) that describe these other industrial activities. You are only required to provide SIC code(s) for industrial activities on site that are listed in Table 1: Sources Covered on page 3 of the permit.

8.  Enter the name, telephone number, and mailing address of the Legal Contact. The Legal Contact 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.

9.  Enter the name, telephone number and mailing address of the Facility Contact if different from the Legal Contact. 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.

10.  Enter invoicing information for billing purposes if different from the Legal Contact (e.g., "Invoice To: Business Office - Accounts Payable"). This must be the same company as the applicant.

B.  STORMWATER DISCHARGE INFORMATION

1.  Briefly describe the activities at the site that have the potential to contaminate stormwater or mine dewatering water. Such activities include the storage of materials or equipment outside, unloading and loading activities, maintenance activities, etc.

2.  Indicate if stormwater is impounded and kept on the site for a period of time before being pumped, drained, or otherwise physically removed from the site by the efforts of the operator of the facility.

3.  Indicate the name(s) of the receiving water(s) that industrial stormwater or mine dewatering water from your facility will discharge to. Your receiving water may be a lake, stream, river, wetland or other waterbody, and may or may not be located adjacent to your facility. Your stormwater or mine dewatering water may discharge directly to the receiving water or indirectly via a storm sewer system, an open drain or ditch, or other conveyance structure. Do NOT list a man-made conveyance, such as a storm sewer system, as your receiving water. Indicate the first natural receiving water your stormwater discharge enters. For example, if your discharge enters a storm sewer system, that empties into Trout Creek, which flows into Pine River, your receiving water is Trout Creek, because it is the first natural waterbody your discharge will reach. Similarly, a discharge into a ditch that feeds Spring Creek should be identified as “Spring Creek” since the ditch is a manmade conveyance. If you discharge into a municipal separate storm sewer system (MS4), you must identify the waterbody into which that portion of the storm sewer discharges. That information should be readily available from the operator of the MS4.

4.  Indicate if any tests have been done on the facility's stormwater runoff or mine dewatering water associated with industrial activities on the site. If no stormwater or mine dewatering discharge data exists, you are not required to test your discharge for application purposes. Attach any sampling results that may be available.

5.  The federal stormwater regulations (40 CFR 122.26(c)) require that your facility be investigated for the presence of non- stormwater discharges. Non-stormwater discharges are any discharges not associated with rain events such as discharges of wash water, boiler blowdown, non-contact cooling water, process wastewater, etc. Certain non-stormwater discharges are authorized under this permit (please see Schedule A, condition 5 of the permit).

Please describe the method used to evaluate your site for the presence of non-stormwater discharges. Methods may include conducting a visual inspection of activities at the site during periods of dry weather to determine if there is any unusual drainage off the site; inspecting site plans or testing drainage lines to confirm that drains being used for non-stormwater discharges are connected to sanitary sewer (sewage treatment plant); or some combination of the above. By signing the application, you certify that such an investigation has been performed. Indicate if any non-stormwater discharges were found during the investigation that are not authorized by this permit or any other existing DEQ permit. For example, if flow was noted, describe the source of the non-stormwater discharge. At the time the application is reviewed, a determination will be made as to whether the non-stormwater discharge needs a permit.

6.  Indicate if any leaks or spills of materials or wastes have occurred at the facility within the last three years.

7.  Indicate if there are any other DEQ permits issued for this site. If so, please describe the permits and provide the permit numbers. Indicate if you are using any of the stormwater outfalls on site to discharge wastewater that is authorized under a different permit.

C.  LAND USE COMPATABILITY STATEMENT

Land Use Compatibility Statement (LUCS) must be signed by local planning official. If there are any conditions placed on the land use approval, the findings must be included. The LUCS form may be obtained from DEQ at: http://www.deq.state.or.us/pubs/permithandbook/lucs.htm.

D.  SIGNATURE OF LEGALLY AUTHORIZED REPRESENTATIVE

A legally authorized representative must sign the application. The following are authorized to sign the document:

•  Corporation — President, secretary, treasurer, vice-president, or any person who performs principal business functions; or a manager of one or more facilities employing more than 250 persons or having gross annual sales or expenditures exceeding $25 million 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

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

E.  APPLICATION SUBMITTAL

Please send the following completed application materials to the appropriate DEQ regional office or DEQ Agent office: Application form; Stormwater Pollution Control Plan (SWPCP); SWPCP checklist; Land Use Compatibility Statement (LUCS), and fees. If applicable, also send a demonstration that your discharge does not or will not contribute to water quality impairments for any pollutant listed in Table 4, Schedule B.1 of the permit. For more information on preparing a SWPCP, please see DEQ’s guidance document, located at http://www.deq.state.or.us/wq/stormwater/industrial.htm. DEQ has entered into agreements with jurisdictions knows as “Agents” to process the permit applications and administer the permits on DEQ’s behalf. If your project is located in one of these areas, please submit your application materials to the Agent, including one electronic and one paper copy of the SWPCP.