2E Application For Approval To Use Water Treatment Additives {50000}

APPLICATION FOR APPROVAL TO USE WATER TREATMENT ADDITIVES State Form 50000 (R / -1 ) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT 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 NOTE: § 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. 1-800-451-6027 (Indiana Residents Only) http://www.in.gov/idem/5157.htm#owq_wastewater 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: è CONTACT PERSON 4. Name of primary contact person (first, last): 5. hone number: 6. E-mail address (optional): è FACILITY 7. Facility address (number and street): City: State: ZIP code: County: 8. hone number: ( ) 9 -mail address (optional): 10. NPDES Permit Number (if facility has an existing permit): (Continued on page 2) American LegalNet, Inc. www.FormsWorkFlow.com Indiana Department of Environmental Management Office of Water Quality NPDES -- Application for Approval to Use Water Treatment Additives 11. Name of water treatment additive: New Previously Approved PART B: ADDITIVE DETAILS 12. Chemical composition of the water treatment additive1: 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 2: 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 2 : 22. Provide a description and method used to control the use of the water treatment additive. What are the procedures on how to maintain 2 this concentration within the system ?: (Continued on page 3) 1 2 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. American LegalNet, Inc. www.FormsWorkFlow.com Indiana Department of Environmental Management Office of Water Quality NPDES -- Application for Approval to Use Water Treatment Additives 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): 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 (LC50) of the additive3: ºF ºC 29. Test species 4: 30. Please explain, or provide attachments to explain, the relation of toxicity topH: 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 LC50 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). 4 3 The test species selected should be characteristic of the more sensitive representative aquatic species in the receiving stream. American LegalNet, Inc. www.FormsWorkFlow.com Indiana Department of Environmental Management Office of Water Quality NPDES -- Appl