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Please print clearly in ink or type and read instructions before filling out this form. All sections are required unless otherwise noted. Application for Coverage Under the General Permit to Discharge Stormwater Associated with Industrial Activity Update Permit Information Permit No. I. Permittee Information (All permit and billing correspondence will be mailed here) Permittee’s Name Company Name Title Universal Business Identifier (UBI) Number Phone No. Fax No . Street Address or P.O. Box E-mail City State Zip + 4 II. Facility Information Name of Facility Date facility began operation or will begin operation Facility Contact Name Phone No. Facility Contact Email Address Fax No. Facility Street Address (or Location Description) Record site location at front door or site entrance Latitude ° ’ ” Longitude ° ’ ” City State Z ip + 4 County Size o f Site in Acres A. List your Standard Industrial Classification (SIC) codes below with the primary SIC code in box 1. You must identify all industrial activities performed at your facility. (See Table 1 in the permit for a list of activities.) You must translate the North American Industry Classification System (NAICS) code for your facility into a SIC code online at http://www.census.gov/epcd/www/naicstab.htm. 1 2 3 4 5 6 B. Type or Nature of Industrial Activities: C. Is this facility a Hazardous Waste Treatment, Storage, and Disposal (TSD) facility regulated under Chapter 173-303 WAC? Yes No D. For Airport Facilities: Is the facility located at an airport where a single facility, or a combination of facilities, use more than 100,000 gallons of glycol-based deicing chemicals and/or 100 tons or more of urea on an average annual basis? Yes No If yes, identify the sampling points that collect runoff from deicing activities: . III. Other Permits / Registration Check all that apply. NPDES Permit (Individual or General Construction Stormwater) Permit No. State Waste Discharge Permit (Ground Discharges) Permit No. 10/09 ---PAGE BREAK--- 10/09 IV. Site Information A. Discharge Point(s) Latitude and Longitude*: Provide latitude and longitude expressed in degrees minutes and seconds for each of your facility’s discharge point(s). List all discharge points. (Please use an extra sheet of paper if necessary.) Please use topographic maps and GPS settings that use the 1983 North American Datum (NAD 83). For the discharge identifier, list the name, number, or letter used on the map to identify the point(s) of discharge. The identifier can only be a maximum of three characters long and must be unique for each discharge point. If you identify more than one discharge point, mark the discharge point(s) you will sample to comply with the permit sampling requirements by checking the “S/P” (sample point) box. Discharge identifier. These cannot be symbols. (maximum of three haract rs ex. 01A) c e Latitude degrees, minutes, seconds Longitude degrees, minutes, seconds S/P Location description ° ’ N ° ’ W ° ’ N ° ’ W ° ’ N ° ’ W ° ’ N ° ’ W ° ’ N ° ’ W NOTE: You must use the unique identifier for the sampling point on each discharge monitoring report (DMR) form you will submit each quarter. Ecology will provide the DMR form when we issue coverage under the permit. B. Receiving Water Latitude / Longitude: Provide latitude and longitude expressed in degrees minutes and seconds of you facility’s discharge where it enters the receiving water(s). Please use topographic maps and GPS settings that use the 1983 North American Datum (NAD 83). List all receiving waters for the site. These receiving waters must be listed in the public notice. (Please use an extra sheet of paper if necessary.) Receiving Water Body Latitude degrees, minutes, seconds Longitude degrees, minutes, seconds ° ’ N ° ’ W ° ’ N ° ’ W ° ’ N ° ’ W ° ’ N ° ’ W ° ’ N ° ’ W 3. Name of Conveyance System: If you discharge to a municipal stormwater system or other stormwater conveyance system Kent stormwater drainage system, roadside ditch), identify the system by name or if unnamed, by other identifier 145th street ditch). *For assistance with latitude and longitude, refer to either of the following websites: http://www.getlatlon.com or http://www.epa.gov/tri/report/siting_tool/index.htm. Please convert all latitude and longitude coordinates into degrees, minutes, seconds format. For help with this process go to: ---PAGE BREAK--- 10/09 V. State Environmental Policy Act (SEPA) Applies only to facilities that began operations after January 1, 2010. Has a SEPA review been completed? Yes No Exempt Type of SEPA determination: Determination of Non-Significance (DNS) Final Environmental Impact Statement (EIS) Mitigated DNS (MDNS) Agency issuing DNS, MDNS, Final EIS, or Exemption: Date: VI. Public Notice New Facilities beginning operations, or existing facilities modifying existing coverage, after January 1, 2010, must publish a public notice at least once a week for two consecutive weeks with seven days in between publications, in a single newspaper of general circulation in the county in which the facility is located. Ecology cannot grant permit coverage earlier than the end of the 30-day public comment period, which begins on the date of the second public notice. Submit (or fax: [PHONE REDACTED]) the application to Ecology on or before the date of the first public notice. If you fax the application to Ecology, you must follow up with hard copy by mail. Date of the first public notice: / / Date of second public notice: / / (Begins 30-day public comment period) Example: Date of the first public notice: 01 / 01 / 2010 Date of second public notice: 01 / 08 / 2010 Name of the newspaper that will publish the public notices: Complete this template using site-specific information. The bold language is required by WAC 173-226- 130 and must be included in its entirety. (Either use the fill-in template below or attach on a separate sheet er, if necessary.) of pap (Name of applicant) (Address of applicant) is seeking coverage/modification of coverage (select one) under the Washington Department of gy’s NPDES General Pe or Stormwater Discharges Associated ndustrial Activities. Ecolo rmit f with I The industrial site, known as (Site name) is located at (Street address) in (Name of nearest city). Operations are due to start up on / started on (select one) (Date). Industrial activities include (Briefly describe the industrial activity). Stormwater from the site discharges to (List unnamed and named receiving waters). Any person desiring to present their views to the Department of Ecology concerning this application may notify Ecology in writing within 30 days from the last date of publication of this notice. Comments may be submitted to: Washington Dept of Ecology Water Quality Program – Industrial Stormwater PO Box 47696 Olympia, WA 98504-7696 ---PAGE BREAK--- 10/09 VII. Certification of Permittee* “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 persons directly responsible for gathering the information, 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.” / Printed Name / Company Title Signature * Date * Federal regulations require this application is signed by one of the following: A. In the case of corporations, by a principal executive officer of at least the level of vice president. B. In the case of a partnership, by a general partner of a partnership. C. In the case of sole proprietorship, by the proprietor. D. In the case of a municipality, state, federal, or other public facility: by either a principal executive officer or ranking elected official. Please return this signed original document to the below address. Make sure you retain a copy for your records. Washington Department of Ecology Water Quality Program – Industrial Stormwater PO Box 47696 Olympia, WA 98504-7696 If you have any questions, please call: • Charles Gilman (360) 407-6437 or [EMAIL REDACTED] for Adams, Asotin, Columbia, Ferry, Franklin, Garfield, Grant, Lincoln, Pend Oreille, Skagit, Snohomish, Spokane, Stevens, Walla Walla, Whatcom, and Whitman counties. • Clay Keown (360) 407-6048 or [EMAIL REDACTED] for Island, King (except Seattle), and San Juan counties. • Josh Klimek (360) 407-7451 or [EMAIL REDACTED] for city of Seattle and Kitsap, Pierce, and Thurston counties • Joyce Smith (360) 407-6858 or [EMAIL REDACTED] for Benton, Chelan, Clallam, Clark, Cowlitz, Douglas, Grays Harbor, Jefferson, Kittitas, Klickitat, Lewis, Mason Okanogan, Pacific, Skamania, Wahkiakum, and Yakima counties. To ask about the availability of this document in a version for the visually impaired call the Water Quality Program at [PHONE REDACTED]. Persons with hearing loss, call 711 for Washington Relay Service. Persons with a speech disability, call [PHONE REDACTED].