Fillable Printable Npdes Application For Approval To Use Water Treatment Additive

Npdes Application For Approval To Use Water Treatment Additive

APPLICATION FOR APPROVAL TO USE WATER

TREATMENT ADDITIVES

State Form 50000 (R / -1)

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

NOTE:

Indiana Dept. of Environmental Management

Office of Water Quality - Permits Section

100 N. Senate Avenue, IGCN Rm 1255

Indianapolis, IN 46204-2251

Telephone: (317) 232-8603 or

1-800-451-6027 (Indiana Residents Only)

http://www.in.gov/idem/5157.htm#owq_wastewat

§ This form must be submitted to the IDEM, Office of Water Quality,

Industrial NPDES Permits Section when applying for a new or renewal

NPDES permit or permit modification.

The information required by this form must be submitted for each

additive submitted for review.

INTRODUCTION

All dischargers are required to disclose information on the water treatment additives in use and to demonstrate that such additives will

not be harmful to aquatic life.

To assure that all discharges from treatment systems using water treatment chemicals meet Indiana Water Quality Standards, the

following information must be submitted to the IDEM, Office of Water Quality, Industrial NPDES Permits Section when applying for a

new or renewal NPDES permit or permit modification. During the preparation of the NPDES permit or modification, this information may

be used to establish permit limitations which comply with all Indiana Water Quality Standards. Additionally, if a permittee changes

water treatment additives during the term of their NPDES permit, the following information must be submitted to the Industrial NPDES

Permits Section, and approval of the change must be received prior to use of the new product(s).

The information required by this form must be submitted for each additive submitted for review. Some of this information may come

from the Material Safety Data Sheet (MSDS) for the additive and should be included with this application. It should also be noted that

biomonitoring of the effluent for the affected outfall(s) may be required. Please provide the following information for each additive.

PART A: GENERAL INFORMATION

1. Name of authorized official (first, last):

2. Name of facility:

3. Mailing address (number and street):

City: State: ZIP code:

èè CONTACT PERSON

4. Name of primary contact person (first, last):

5. 7HOHShone number:

6.E-mail address (optional):

èè FACILITY

7. Facility address (number and street):

City: State: ZIP code: County:

8. 7HOHShone number: ( )

9(-mail address (optional):

10. NPDES Permit Number (if facility has an existing permit):

(Continued on page 2)

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Indiana Department of Environmental Management NPDES — Application for Approval to Use Water Treatment Additives

Office of Water Quality

PART B: ADDITIVE DETAILS

11. Name of water treatment additive:

New

Previously Approved

12. Chemical composition of the water treatment additive

13. What is the feed or dosage rate in grams/24 hr.

period. (This may be provided in fluid ounces):

14. If more than one Outfall is covered by this permit, which Outfall does the use of this water treatment additive affect?:

15. Name any ingredient(s) that may be present and may cause toxicity at the proposed Outfall. If known, provide the discharge

concentration of the ingredients (mg/l):

16. Provide the location where the additive is put into use

17. Provide the duration of use for the additive (hours per day and days per year):

__________hours/day ___________days/year

PART C: ADDITIVE CONCENTRATION

18. Concentration (mg/l) of the water treatment

additive used in the treatment system:

19. The concentration (mg/l) of the water treatment

additive used in the final discharge (if known):

20. Discharge concentration of the water treatment

additive (mg/l):

21. Please explain how the final discharge concentration stated for item # 20 was arrived at

22. Provide a description and method used to control the use of the water treatment additive. What are the procedures on how to maintain

this concentration within the system

(Continued on page 3)

Proprietary information may be submitted separately by the manufacturer or distributor and will be kept confidential.

If necessary, this information may be provided on supplementary attachments.

Indiana Department of Environmental Management NPDES — Application for Approval to Use Water Treatment Additives

Office of Water Quality

PART D: SYSTEM & DISCHARGE DETAILS

23. Provide the hardness of the discharge water:

24. The temperature of the treatment system using the

water treatment additive (specify ºF or ºC):

ºF ºC

25. The Blowdown Rate (MGD) from the treatment

system using the water treatment additive:

26. The average flow (MGD) of all waste streams being

discharged through the affected Outfall:

27. The pH of the treatment system using the water

treatment additive:

PART E: CHEMICAL PROPERTIES/TOXICITY DATA

è For determining safe concentrations of the water treatment additives, the following information should also be submitted or addressed.

Submit the supporting documentation (i.e., Material Safety Data Sheets) as attachments to this application.

28. Toxicity (LC

) of the additive

29. Test species

30. Please explain, or provide attachments to explain, the relation of toxicity to pH:

31. Please explain, or provide attachments to explain the relationship of toxicity to water hardness:

(Continued on page 4)

As determined by 96-hour flow through bioassays for fish (preferably fathead minnow (Pimephales promelas) or bluegill (Lepomis macrochirus) for

warmwater species or rainbow trout (Salmo gairdneri) for coldwater species) and a 48-hour static renewal for invertebrates (preferably of the genera

Daphnia or Ceriodaphnia). Testing procedures to determine LC

values should follow U.S. EPA Guidelines. Static bioassays are acceptable only if the

treatment chemical is persistent. The test temperature should be maintained at 20º Celsius (68º Fahrenheit) for coldwater species and at 30º Celsius

(86º Fahrenheit) for warmwater species (higher test temperatures are chosen in order to simulate worst case conditions. Lower test temperatures may

be used only if the thermal tolerance of the chosen representative aquatic species is below the recommended test temperatures).

The test species selected should be characteristic of the more sensitive representative aquatic species in the receiving stream.

Indiana Department of Environmental Management NPDES — Application for Approval to Use Water Treatment Additives

Office of Water Quality

PART E: CHEMICAL PROPERTIES/TOXICITY DATA FRQWLQXHG

èè Product persistence in the environment and N Octanol-Water Partition Coefficient and Bioconcentration Factor (BCF) (if available).

32. Provide the decay rate of the product, if known. This should be stated at a pH level within ½ pH standard unit within the handling

system

. (Please provide copies of the sources of this data as attachments to this application.):

33. Provide any additional information or attach any additional documentation to help in evaluating the use of this water treatment

additive:

PART F: SIGNATURE

This information will be reviewed and permission to use the water treatment additive may be granted either by letter, permit limitations, or

permit modification, if the discharger has supplied the requested product information and toxicity data that will enable IDEM to establish

permissible concentrations in each individual case. If the initial information is not sufficient to allow for the establishment of a safe

concentration, additional information will be requested.

Proprietary information regarding the chemical composition of any water treatment additive will be kept confidential in accordance with the

terms of 327 IAC 12.1. Claims of confidentiality must be made at the time of submittal; the information must be properly marked, segregated

and secured at the time of submittal; and the person or company requesting confidentiality must provide justification as to why the information

meets the criteria for it to be maintained as a trade secret, privileged information or confidential in accordance with 327 IAC 12.1 .

This application should include the following and must be signed by a person in responsible charge to be valid. This signature attests to the

following:

"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) (Title)

___________________________________________ _________________________________________

(Signature) (Date Signed) (mm/dd/yyyy)

The half life is the time required for the initial product to degrade to half of its original concentration.