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0210-PM-PIO0001 Rev. 10/2020 Application Page 1 of 8 COMMONWEALTH OF DEPARTMENT OF ENVIRONMENTAL PROTECTION GENERAL INFORMATION FORM – AUTHORIZATION APPLICATION Before completing this General Information Form (GIF), read the step-by-step instructions provided in this application package. This form is used by the Department of Environmental Protection (DEP) to inform our programs regarding what other DEP permits or authorizations may be needed for the proposed project or activity. This version of the General Information Form (GIF) must be completed and returned with any program-specific application being submitted to the DEP. Related ID#s (If Known) DEP USE ONLY Client ID# APS ID# Date Received & General Notes Site ID# Auth ID# Facility ID# CLIENT INFORMATION DEP Client ID# Client Type / Code Dun & Bradstreet ID# Legal Organization Name or Registered Fictitious Name Employer ID# (EIN) Is the EIN a SSN? Yes NO State of Incorporation or Registration of Fictious Name Corporation LLC Partnership LLP LP Sole Proprietorship Association/Organization Estate/Trust Other Individual Last Name First Name MI Suffix Additional Individual Last Name First Name MI Suffix Mailing Address Line 1 Mailing Address Line 2 Address Last Line – City State ZIP+4 Country Client Contact Last Name First Name MI Suffix Client Contact Title Phone Ext Cell Phone Email Address FAX SITE INFORMATION DEP Site ID# Site Name EPA ID# Estimated Number of Employees to be Present at Site Description of Site Tax Parcel ID(s): County Name(s) Municipality(ies) City Boro Twp State Site Location Line 1 Site Location Line 2 Site Location Last Line – City State ZIP+4 Detailed Written Directions to Site ---PAGE BREAK--- 0210-PM-PIO0001 Rev. 10/2020 Application Page 2 of 8 Site Contact Last Name First Name MI Suffix Site Contact Title Site Contact Firm Mailing Address Line 1 Mailing Address Line 2 Mailing Address Last Line – City State ZIP+4 Phone Ext FAX Email Address NAICS Codes (Two- & Three-Digit Codes – List All That Apply) 6-Digit Code (Optional) Client to Site Relationship FACILITY INFORMATION Modification of Existing Facility Yes No 1. Will this project modify an existing facility, system, or activity? 2. Will this project involve an addition to an existing facility, system, or activity? If “Yes”, check all relevant facility types and provide DEP facility identification numbers below. Facility Type DEP Fac ID# Facility Type DEP Fac ID# Air Emission Plant Industrial Minerals Mining Operation Beneficial Use (water) Laboratory Location Blasting Operation Land Recycling Cleanup Location Captive Hazardous Waste Operation Mine Drainage Treatment / Land Recycling Project Location Coal Ash Beneficial Use Operation Municipal Waste Operation Coal Mining Operation Oil & Gas Encroachment Location Coal Pillar Location Oil & Gas Location Commercial Hazardous Waste Operation Oil & Gas Water Poll Control Facility Dam Location Public Water Supply System Deep Mine Safety Operation -Anthracite Radiation Facility Deep Mine Safety Operation -Bituminous Residual Waste Operation Deep Mine Safety Operation -Ind Minerals Storage Tank Location Encroachment Location (water, wetland) Water Pollution Control Facility Erosion & Sediment Control Facility Water Resource Explosive Storage Location Other: Latitude/Longitude Latitude Longitude Point of Origin Degrees Minutes Seconds Degrees Minutes Seconds Horizontal Accuracy Measure Feet Meters Horizontal Reference Datum Code North American Datum of 1927 North American Datum of 1983 World Geodetic System of 1984 Horizontal Collection Method Code Reference Point Code Altitude Feet Meters Altitude Datum Name The National Geodetic Vertical Datum of 1929 The North American Vertical Datum of 1988 (NAVD88) Altitude (Vertical) Location Datum Collection Method Code Geometric Type Code Data Collection Date Source Map Scale Number Inch(es) = Feet Centimeter(s) = Meters ---PAGE BREAK--- 0210-PM-PIO0001 Rev. 10/2020 Application Page 3 of 8 PROJECT INFORMATION Project Name Project Description Project Consultant Last Name First Name MI Suffix Project Consultant Title Consulting Firm Mailing Address Line 1 Mailing Address Line 2 Address Last Line – City State ZIP+4 Phone Ext FAX Email Address Time Schedules Project Milestone (Optional) 1. Is the project located in or within a 0.5-mile radius of an Environmental Justice community as defined by DEP? Yes No To determine if the project is located in or within a 0.5-mile radius of an environmental justice community, please use the online Environmental Justice Areas Viewer. 2. Have you informed the surrounding community prior to submitting the application to the Department? Method of notification: Yes No 3. Have you addressed community concerns that were identified? Yes No N/A If no, please briefly describe the community concerns that have been expressed and not addressed. 4. Is your project funded by state or federal grants? Yes No Note: If “Yes”, specify what aspect of the project is related to the grant and provide the grant source, contact person and grant expiration date. Aspect of Project Related to Grant Grant Source: Grant Contact Person: Grant Expiration Date: 5. Is this application for an authorization on Appendix A of the Land Use Policy? (For referenced list, see Appendix A of the Land Use Policy attached to GIF instructions) Yes No Note: If “No” to Question 5, the application is not subject to the Land Use Policy. If “Yes” to Question 5, the application is subject to this policy and the Applicant should answer the additional questions in the Land Use Information section. ---PAGE BREAK--- 0210-PM-PIO0001 Rev. 10/2020 Application Page 4 of 8 LAND USE INFORMATION Note: Applicants should submit copies of local land use approvals or other evidence of compliance with local comprehensive plans and zoning ordinances. 1. Is there an adopted county or multi-county comprehensive plan? Yes No 2. Is there a county stormwater management plan? Yes No 3. Is there an adopted municipal or multi-municipal comprehensive plan? Yes No 4. Is there an adopted county-wide zoning ordinance, municipal zoning ordinance or joint municipal zoning ordinance? Yes No Note: If the Applicant answers “No” to either Questions 1, 3 or 4, the provisions of the PA MPC are not applicable and the Applicant does not need to respond to questions 5 and 6 below. If the Applicant answers “Yes” to questions 1, 3 and 4, the Applicant should respond to questions 5 and 6 below. 5. Does the proposed project meet the provisions of the zoning ordinance or does the proposed project have zoning approval? If zoning approval has been received, attach documentation. Yes No 6. Have you attached Municipal and County Land Use Letters for the project? Yes No COORDINATION INFORMATION Note: The PA Historical and Museum Commission must be notified of proposed projects in accordance with DEP Technical Guidance Document 012-0700-001 utilizing the Project Review Form. If the activity will be a mining project mining of coal or industrial minerals, coal refuse disposal and/or the operation of a coal or industrial minerals preparation/processing facility), respond to questions 1.0 through 2.5 below. If the activity will not be a mining project, skip questions 1.0 through 2.5 and begin with question 3.0. 1.0 Is this a coal mining project? If “Yes”, respond to 1.1-1.6. If “No”, skip to Question 2.0. Yes No 1.1 Will this coal mining project involve coal preparation/ processing activities in which the total amount of coal prepared/processed will be equal to or greater than 200 tons/day? Yes No 1.2 Will this coal mining project involve coal preparation/ processing activities in which the total amount of coal prepared/processed will be greater than 50,000 tons/year? Yes No 1.3 Will this coal mining project involve coal preparation/ processing activities in which thermal coal dryers or pneumatic coal cleaners will be used? Yes No 1.4 For this coal mining project, will sewage treatment facilities be constructed and treated waste water discharged to surface waters? Yes No 1.5 Will this coal mining project involve the construction of a permanent impoundment meeting one or more of the following criteria: a contributory drainage area exceeding 100 acres; a depth of water measured by the upstream toe of the dam at maximum storage elevation exceeding 15 feet; an impounding capacity at maximum storage elevation exceeding 50 acre-feet? Yes No 1.6 Will this coal mining project involve underground coal mining to be conducted within 500 feet of an oil or gas well? Yes No 2.0 Is this a non-coal (industrial minerals) mining project? If “Yes”, respond to 2.1-2.6. If “No”, skip to Question 3.0. Yes No 2.1 Will this non-coal (industrial minerals) mining project involve the crushing and screening of non-coal minerals other than sand and gravel? Yes No 2.2 Will this non-coal (industrial minerals) mining project involve the crushing and/or screening of sand and gravel with the exception of wet sand and gravel operations (screening only) and dry sand and gravel operations with a capacity of less than 150 tons/hour of unconsolidated materials? Yes No ---PAGE BREAK--- 0210-PM-PIO0001 Rev. 10/2020 Application Page 5 of 8 2.3 Will this non-coal (industrial minerals) mining project involve the construction, operation and/or modification of a portable non- metallic non-coal) minerals processing plant under the authority of the General Permit for Portable Non-metallic Mineral Processing Plants BAQ-PGPA/GP-3)? Yes No 2.4 For this non-coal (industrial minerals) mining project, will sewage treatment facilities be constructed and treated waste water discharged to surface waters? Yes No 2.5 Will this non-coal (industrial minerals) mining project involve the construction of a permanent impoundment meeting one or more of the following criteria: a contributory drainage area exceeding 100 acres; a depth of water measured by the upstream toe of the dam at maximum storage elevation exceeding 15 feet; an impounding capacity at maximum storage elevation exceeding 50 acre-feet? Yes No 3.0 Will your project, activity, or authorization have anything to do with a well related to oil or gas production, have construction within 200 feet of, affect an oil or gas well, involve the waste from such a well, or string power lines above an oil or gas well? If “Yes”, respond to 3.1-3.3. If “No”, skip to Question 4.0. Yes No 3.1 Does the oil- or gas-related project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a watercourse, floodway or body of water (including wetlands)? Yes No 3.2 Will the oil- or gas-related project involve discharge of industrial wastewater or stormwater to a dry swale, surface water, ground water or an existing sanitary sewer system or storm water system? If “Yes”, discuss in Project Description. Yes No 3.3 Will the oil- or gas-related project involve the construction and operation of industrial waste treatment facilities? Yes No 4.0 Will the project involve a construction activity that results in earth disturbance? If “Yes”, specify the total disturbed acreage. Yes No 4.0.1 Total Disturbed Acreage 4.0.2 Will the project discharge or drain to a special protection water (EV or HQ) or an EV wetland? Yes No 4.0.3 Will the project involve a construction activity that results in earth disturbance in the area of the earth disturbance that are contaminated at levels exceeding residential or non-residential medium-specific concentrations (MSCs) in 25 Pa. Code Chapter 250 at residential or non- residential construction sites, respectively? Yes No 5.0 Does the project involve any of the following: water obstruction and/or encroachment, wetland impacts, or floodplain project by the Commonwealth/political subdivision or public utility? If “Yes”, respond to 5.1-5.7. If “No”, skip to Question 6.0. Yes No 5.1 Water Obstruction and Encroachment Projects – Does the project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a watercourse, floodway or body of water? Yes No 5.2 Wetland Impacts – Does the project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a wetland? Yes No 5.3 Floodplain Projects by the Commonwealth, a Political Subdivision of the Commonwealth or a Public Utility – Does the project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a floodplain? Yes No 5.4 Is your project an interstate transmission natural gas pipeline? Yes No ---PAGE BREAK--- 0210-PM-PIO0001 Rev. 10/2020 Application Page 6 of 8 5.5 Does your project consist of linear construction activities which result in earth disturbance in two or more DEP regions AND three or more counties? Yes No 5.6 Does your project utilize Floodplain Restoration as a best management practice for Post Construction Stormwater Management? Yes No 5.7 Does your project utilize Class V Gravity / Injection Wells as a best management practice for Post Construction Stormwater Management? Yes No 6.0 Will the project involve discharge of construction related stormwater to a dry swale, surface water, ground water or separate storm water system? Yes No 6.1 Will the project involve discharge of industrial waste stormwater or wastewater from an industrial activity or sewage to a dry swale, surface water, ground water or an existing sanitary sewer system or separate storm water system? Yes No 7.0 Will the project involve the construction and operation of industrial waste treatment facilities? Yes No 8.0 Will the project involve construction of sewage treatment facilities, sanitary sewers, or sewage pumping stations? If “Yes”, indicate estimated proposed flow (gal/day). Also, discuss the sanitary sewer pipe sizes and the number of pumping stations/treatment facilities/name of sewage facilities in the Project Description, where applicable. Yes No 8.0.1 Estimated Proposed Flow (gal/day) 9.0 Will the project involve the subdivision of land, or the generation of 800 gpd or more of sewage on an existing parcel of land or the generation of an additional 400 gpd of sewage on an already- developed parcel, or the generation of 800 gpd or more of industrial wastewater that would be discharged to an existing sanitary sewer system? Yes No 9.0.1 Was Act 537 sewage facilities planning submitted and approved by DEP? If “Yes” attach the approval letter. Approval required prior to 105/NPDES approval. Yes No 10.0 Is this project for the beneficial use of biosolids for land application within If “Yes” indicate how much (i.e. gallons or dry tons per year). Yes No 10.0.1 Gallons Per Year (residential septage) 10.0.2 Dry Tons Per Year (biosolids) 11.0 Does the project involve construction, modification or removal of a dam? If “Yes”, identify the dam. Yes No 11.0.1 Dam Name 12.0 Will the project interfere with the flow from, or otherwise impact, a dam? If “Yes”, identify the dam. Yes No 12.0.1 Dam Name 13.0 Will the project involve operations (excluding during the construction period) that produce air emissions NOX, VOC, etc.)? Yes No 13.0.1 If “Yes”, is the operation subject to the agricultural exemption in 35 P.S. § 4004.1? Yes No 13.0.2 If the answer to 13.0.1 is “No”, identify each type of emission followed by the estimated amount of that emission. Enter all types & amounts of emissions; separate each set with semicolons. ---PAGE BREAK--- 0210-PM-PIO0001 Rev. 10/2020 Application Page 7 of 8 14.0 Does the project include the construction or modification of a drinking water supply to serve 15 or more connections or 25 or more people, at least 60 days out of the year? If “Yes”, check all proposed sub-facilities. Yes No 14.0.1 Number of Persons Served 14.0.2 Number of Employee/Guests 14.0.3 Number of Connections 14.0.4 Sub-Fac: Distribution System Yes No 14.0.5 Sub-Fac: Water Treatment Plant Yes No 14.0.6 Sub-Fac: Source Yes No 14.0.7 Sub-Fac: Pump Station Yes No 14.0.8 Sub Fac: Transmission Main Yes No 14.0.9 Sub-Fac: Storage Facility Yes No 15.0 Will your project include infiltration of storm water or waste water to ground water within one-half mile of a public water supply well, spring or infiltration gallery? Yes No 16.0 Is your project to be served by an existing public water supply? If “Yes”, indicate name of supplier and attach letter from supplier stating that it will serve the project. Yes No 16.0.1 Supplier’s Name 16.0.2 Letter of Approval from Supplier is Attached Yes No 17.0 Will this project be served by on-lot drinking water wells? Yes No 18.0 Will this project involve a new or increased drinking water withdrawal from a river, stream, spring, lake, well or other water bod(ies)? If “Yes”, reference Safe Drinking Water Program. Yes No 18.0.1 Source Name 19.0 Will the construction or operation of this project involve treatment, storage, reuse, or disposal of waste? If “Yes”, indicate what type hazardous, municipal (including infectious & chemotherapeutic), residual) and the amount to be treated, stored, re-used or disposed. Yes No 19.0.1 Type & Amount 20.0 Will your project involve the removal of coal, minerals, contaminated media, or solid waste as part of any earth disturbance activities? Yes No 21.0 Does your project involve installation of a field constructed underground storage tank? If “Yes”, list each Substance & its Capacity. Note: Applicant may need a Storage Tank Site Specific Installation Permit. Yes No 21.0.1 Enter all substances & capacity of each; separate each set with semicolons. 22.0 Does your project involve installation of an aboveground storage tank greater than 21,000 gallons capacity at an existing facility? If “Yes”, list each Substance & its Capacity. Note: Applicant may need a Storage Tank Site Specific Installation Permit. Yes No 22.0.1 Enter all substances & capacity of each; separate each set with semicolons. 23.0 Does your project involve installation of a tank greater than 1,100 gallons which will contain a highly hazardous substance as defined in DEP’s Regulated Substances List, 2570-BK-DEP2724? If “Yes”, list each Substance & its Capacity. Note: Applicant may need a Storage Tank Site Specific Installation Permit. Yes No 23.0.1 Enter all substances & capacity of each; separate each set with semicolons. ---PAGE BREAK--- 0210-PM-PIO0001 Rev. 10/2020 Application Page 8 of 8 24.0 Does your project involve installation of a storage tank at a new facility with a total AST capacity greater than 21,000 gallons? If “Yes”, list each Substance & its Capacity. Note: Applicant may need a Storage Tank Site Specific Installation Permit. Yes No 24.0.1 Enter all substances & capacity of each; separate each set with semicolons. NOTE: If the project includes the installation of a regulated storage tank system, including diesel emergency generator systems, the project may require the use of a Department Certified Tank Handler. For a full list of regulated storage tanks and substances, please go to www.dep.pa.gov search term storage tanks 25.0 Will the intended activity involve the use of a radiation source? Yes No CERTIFICATION I certify that I have the authority to submit this application on behalf of the applicant named herein and that the information provided in this application is true and correct to the best of my knowledge and information. For applicants supplying an EIN number: I am applying for a permit or authorization from the Department of Environmental Protection (DEP). As part of this application, I will provide DEP with an accurate EIN number for the applicant entity. By filing this application with DEP, I hereby authorize DEP to confirm the accuracy of the EIN number provided with the Department of Revenue. As applicant, I further consent to the Department of Revenue discussing the same with DEP prior to issuance of the Commonwealth permit or authorization. Type or Print Name Signature Title Date