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Section A - General Information

1. Provide a description of the treatment devices and processes that will be used for treating the contaminated groundwater.
2. Describe the pollutant loadings, flow rates, design capacity, physical size, and operating procedures of each treatment device and process identified above for treating the contaminated groundwater
3. Do you have a Groundwater Treatment System Operator?
If yes, provide the Groundwater Treatment System Operator's name, title, and phone number below.
1. Yes
1. No
Groundwater Treatment System Operator Contact Information
If you selected option Yes above, provide the Groundwater Treatment Operator's Name, Title, and Phone Number below.
3a. Name
3b. Title
3c. Phone number
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1. Characteristics of discharge - Identify what groundwater contaminants will be present or are suspected to be present in the groundwater being treated (provide analytical results)*
2. Identify any chemicals or additives used in the groundwater treatment process
3. Describe all chemical and waste storage containers that will be kept on site. Inclde the location, container size and type, and contents of each chemical or waste storage container
4. Have you developed an accidental spill plan for this groundwater remediation operation?
1. Yes - Upload a copy below
2. No - You must submit a plan within 60 days of permit issuance
3. Not applicable - No floor drains or only domestic wastes
Upload Accidental Spill Plan
If you selected "yes" above, upload a copy of your Accidental Spill Plan here.
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1. Non-discharged wastes
Will there be any waste liquids or sludges generated by the groundwater treatment process that will NOT be disposed of in the sanitary sewer?
1. Yes
2. No
a. Waste Generated
Quantity (Year)
Disposal method
b. Waste Generated
Quantity (Year)
Disposal method
c. Waste Generated
Quantity
Disposal method
d. Waste Generated
Quantity
Disposal method
2. Environmental Permits
List all other environmental permits applicable to this groundwater remediation (Federal, State, local).
a. Regulatory Agency*
Permit Number*
Expiration date*
Expiration date
b. Regulatory Agency
Permit Number
Expiration date
Expiration date
c. Regulatory Agency
Permit Number
Expiration Date
Expiration Date
d. Regulatory Agency
Permit Number
Expiration date
Expiration date
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Electronic signature*
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. 4) You agree with the following statement: 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 ensure 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, hat 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 fines and imprisonment for knowing violations.
1. I agree.
Full Name*
Title*
Company name*
Mailing Address*
City*
State*
Zip Code*
Email Address*
Phone number*

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