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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT MUNICIPAL NPDES PERMIT SECTION 65-42 PS 100 North Senate Avenue, Room N1203 Indianapolis, Indiana 46204-2251

PRELIMINARY EFFLUENT LIMITATION APPLICATION
State Form 53912 (1-09) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

INSTRUCTIONS:

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See page 3 for an overview of this application Mail this completed application to the above address. For questions or forms related to preliminary effluent limitations, or NPDES permits please call 317/232-8760. For questions or forms related to Construction Permits, please contact staff of the Facility Construction Section at 317/232-5579.

Person Completing Application Name: Title (Consultant, Compliance Manager, etc.): Telephone Number(s): Fax Number: E-mail Address: Mailing Address (number and street, city, state, and ZIP code): Facility Responsible Party Name: Title of Responsible Party (Owner, C.E.O., etc.): Telephone Number(s): Fax Number: E-mail Address: Mailing Address (number and street, city, state, and ZIP code): Facility Certified Operator (Optional) Name: Certification Number: Telephone Number(s): Fax Number: E-mail Address: Mailing Address (number and street, city, state, and ZIP code): Facility Information Name: New or Existing Facility (Check one): New Existing County Facility is/will be in: Nearest City or Town: If New Facility, list the identity and distance to the nearest publicly-owned wastewater treatment plant's collection system (sewer lines): If Existing Facility, NPDES Permit Number: Facility Telephone Number: Facility Fax Number: Facility Mailing Address (number and street, city, state, and ZIP code):

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Facility Location (Existing and/or Proposed Locations): Note: Provide street address as well as latitude and longitude information; also include a copy of a portion of a topographic map as an attachment to this application, which indicates the exact location and/or proposed location(s) of the facility.

Outfall Location (Existing and/or proposed Location(s)): Note: Use latitude and longitude to describe existing and/or proposed outfall location(s); also include a copy of a portion of a topographic map indicating these exact locations and/or proposed location(s).

Receiving Stream If an Existing Facility, provide the name of the stream, lake, drain, etc. that the plant outfall discharges into currently (i.e. "An unnamed ditch to the Wabash River").

If a New Facility, or if proposing to relocate the outfall of an existing facility, provide the name of the stream, lake, drain, etc. that the plant outfall is proposed to discharge into.

Type of wastewater to be treated (i.e. sanitary only, commercial and sanitary, sanitary and industrial, landfill leachate, etc.). If an existing facility, list the current average design flow in Millions of Gallons per Day (MGD) MGD (New or Existing Facility) Proposed average design flow(s) in MGD MGD Treatment Facility Description Note: For each type of treatment selected, please provide specific information regarding the type of treatment proposed such as bio-mechanical (i.e. extended aeration, oxidation ditch, sequential batch reactor), or a waste stabilization lagoon, an aerated lagoon, etc. Please specify the type of disinfection equipment to be utilized.

Additional Information Please provide any additional information which might be helpful in describing the proposed activity or special concerns. Feel free to attach additional pages as necessary.

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OVERVIEW FOR PRELIMINARY EFFLUENT LIMITATIONS PURPOSE This application form is utilized by the Indiana Department of Environmental Management, Office of Water Quality, Municipal NPDES Permit Section's staff to gather information necessary to provide the applicant with accurate and timely preliminary effluent limitations for sanitary-type National Pollutant Discharge Elimination System (NPDES) permits. Preliminary effluent limitations are the anticipated effluent limitations for pollutants that will be included in a subsequently issued or modified NPDES permit. These limitations are a pre-requisite to the submittal of an NPDES permit application or a construction permit application. Factors affecting the preliminary effluent limitations include the type of treatment selected, the volume of water discharged, the location of the discharge, the characteristics of the receiving water body, et al. Once preliminary effluent limitations are developed for the proposed activity, a letter including these limitations will be sent to the applicant by this Office. The applicant may then proceed with the design phase of the project and submit a construction permit application (if required) and then an NPDES permit application or modification request. Applications for both the NPDES permit and the construction permit should include a copy of the preliminary effluent limitations letter sent by this Office. APPLICATION FEES No fees are required for preliminary effluent limitation applications at this time. Fees are required for NPDES and Construction Permit applications. REASONABLE SCOPE More than one average design flow, treatment method, or receiving stream scenario may be submitted for preliminary effluent limitation development at one time. However, this Office reserves the right to request refinement of any request which includes multiple scenarios to provide the best use of Office resources to serve all applicants. APPLICATION DEFICIENCIES If the applicant fails to provide all necessary information, or if unique information is required for the proposed activity, this Office will attempt to obtain the information from the applicant via phone or via mailing in a reasonable time frame. Failure to submit the necessary information requested in a timely manner will result in delays in generating preliminary effluent limitations.

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