Submission of this application constitutes notice that the Applicant identified in this application is seeking coverage under Ohio EPA’s beneficial use individual permit program pursuant to Ohio Administrative Code (OAC) Chapter 3745-599. Becoming a permittee obligates the Applicant to comply with the terms and conditions of the individual permit. Complete all required information as indicated by the instructions.
A check for $350 must accompany this form and be made payable to “Treasurer, State of Ohio”.
1.Project Name:
2.Applicant’s Information:
Name:Mailing Address:
City: / State: / Zip:
Contact Name:
Title:
Phone: / () - / Fax: / () - / E-mail:
3.Generator or Source of Material Information:
Name:Mailing Address:
City: / State: / Zip:
Contact Name:
Title:
Phone: / () - / Fax: / () - / E-mail:
[1]Optional: Second Generator or Second Source of Material Information:
Name:Mailing Address:
City: / State: / Zip:
Contact Name:
Title:
Phone: / () - / Fax: / () - / E-mail:
4.Project Location (check N/A if there is no specific proposed location):
Address or Location Description:County:
City: / State: / Zip:
Latitude: / Must be between 38 and 43, use all 6 decimals of precision whenever possible
Longitude: / must be between -85 and -80, use all 6 decimals of precision whenever possible.
N/A
5. Project Information
a)Describe the proposed beneficial use(s) of materials (agronomic uses, soil blends, structural fill, etc.) and amount of material for each beneficial use.
If the above information is provided in an attachment, provide attachment title or page number here:b)Describe the disposal or other management method(s) for any material not beneficially used.
If the above information is provided in an attachment, provide attachment title or page number here:6.Wetlands
Will wetlands be disturbed during this beneficial use project?
/ Yes NoIf yes, enter the date the 401/404 permit application was submitted / //
7.Designated Ohio, Wild, Scenic, & Recreational Rivers
Is this project located within 1000 feet of a designated wild, scenic, and recreational river?Yes No
See for additional information
8.Will one or more acres be disturbed during this project?
Yes NoIf Yes, enter the date the NOI for coverage under the construction storm water NPDES permit
was submitted: / // / and the date coverage was granted: / //
9.Compliance Status
a)Will this project connect to a collection/treatment system that has a NPDES permit?
Yes NoIf Yes, list federal and state permit numbers:
OH
b)Is this application filed in compliance with findings and orders, a consent decree, and/or NPDES permit schedule?
Yes NoIf Yes, effective date of the document containing the schedule: / //
10.Estimated Project Schedule:
Beginning project date: / // / Ending project date: / //11.Material Information
a)Amount of material generated: dry tons/year.
b)Amount of material proposed for beneficial use: dry tons/year.
12.Material Storage
a)Storage capacity for the materials intended for beneficial use: dry tons/year.
b)Describe the method or methods used for storage of the materials intended for beneficial use and total amount of for each storage method
13.Please provide documentation which demonstrates that the material proposed as a beneficial use byproduct for beneficial use is not a hazardous waste as defined by Ohio Revised Code Section 3734.01, OAC Rule 3745-50-10(A) and OAC Rule 3745-51-03. Applicant may use sampling and analysis data or generator knowledge to demonstrate this determination. If there is not TCLP Method 1311 analysis for the beneficial use byproduct, see EPA publication SW-846, “Test Methods for Evaluating Solid Waste, Physical/Chemical Methods (SW-846),” Section 1.2 of the TCLP Method 1311 does allow for a total constituent analysis in lieu of the TCLP extraction.
If the above information is provided in an attachment, provide attachment title or page number here:14.Please provide a description of the physical and chemical characteristics of each beneficial use byproduct as generated, including a description of the generating process, the product generated, and a list of the feedstock, input materials, and raw materials used to generate the beneficial use byproduct.
If the above information is provided in an attachment, provide attachment title or page number here:15.Please provide a description of the way the beneficial use byproduct is intended to be managed and beneficially used in accordance with OAC Rule 3745-599-35.
a)How will the beneficial use byproduct provide a useful contribution to the commercial, production or manufacturing process (contributes a valuable ingredient or substitute for a product)?b)How will the beneficial use byproduct be beneficially used to produce a valuable product?
c)How with the beneficial use byproduct be beneficially used as an effective substitute for a commercial product, a soil additive or amendment, or as an ingredient?
If the above information is provided in an attachment, provide attachment title or page number here:
16.If the beneficial use byproduct is being proposed for the beneficial use as an agronomic benefit, please provide a demonstration of the agronomic benefit.
If the above information is provided in an attachment, provide attachment title or page number here:17.Please provide a description of the BMPs that will be used when transporting, storing, and handling the beneficial use byproduct to ensure the byproduct is not released to the environment.
If the above information is provided in an attachment, provide attachment title or page number here:18.If you know the location for the proposed beneficial use, please provide the location and environs of each location of the proposed beneficial use. If the location has a Covenant Not to Sue governing the Property, is in an Urban Setting Designation, or under the Resource Conservation and Recovery Act, or Cessation of Regulated Operation, or the Comprehensive Environmental Response, Compensation, and Liability Act, please provide all documentation of such activities and maps of the parcels covered under the activities.
If the above information is provided in an attachment, provide attachment title or page number here:19.Please provide a description of the chemical characteristics, including the leaching characteristics, of runoff from the beneficial use byproduct, if the beneficial use byproduct will be applied to the land.
If the above information is provided in an attachment, provide attachment title or page number here:20.An analysis for each constituent listed for each beneficial use byproduct proposed as a beneficial use byproduct for beneficial use shall be provided. These listed constituents shall be the constituents of concern for each beneficial use byproduct. If a constituent of concern exceeds the totals analysis limit or leaching analysis limit included in a general beneficial use permit, please explain how the exceedance or beneficial use of the beneficial use byproduct will not adversely impact public health or safety or the environment.For example, explain how BMPs will be put in place to prevent leaching to waters of the state or from the property.
Analysis provided? YES NO
Attachment title or page number:21.Please identify the methods selected for analyzing the constituents of concern for each beneficial use byproduct and an explanation of the rationale for using each selected method.
If the above information is provided in an attachment, provide attachment title or page number here:22.Please provide a description of the representative sampling strategy using sampling methods in accordance with OAC rule 3745-599-60. The description of the sampling strategy shall include at a minimum the following:
a)An explanation of whether the representative sampling strategy characterizes the beneficial use byproduct by volume or characterizes the beneficial use byproduct as generated through time.
If the above information is provided in an attachment, provide attachment title or page number here:b)The location and the number of all grab samples, composite samples and incremental samples taken to define the average properties of the beneficial use byproduct. The number and location of samples shall be chosen so as not to miss areas of high chemical concentration.
If the above information is provided in an attachment, provide attachment title or page number here:c)A narrative explaining whether a sufficient number of samples were collected by the applicant to ensure that the collected samples truly represent the average properties of the entire beneficial use byproduct. In the case of simple random sampling using grab samples, the applicant shall perform a statistical analysis of the data. If composite or incremental samples were used for the sampling method, and a statistical analysis is not practical, the applicant shall demonstrate to the satisfaction of the director that the sampling method is valid and defensible for the purpose for which the data was collected.
If the above information is provided in an attachment, provide attachment title or page number here:23.Please provide a description of the sample handling techniques and shipping procedures selected to maintain the sample integrity, including sample preservation and chain of custody. The description shall also set forth the quality control procedures and sampling protocols used to obtain representative samples of the beneficial use byproduct.
If the above information is provided in an attachment, provide attachment title or page number here:24.A written discussion of the analytical results used to justify the beneficial use of the beneficial use byproduct for the beneficial use specified in the individual beneficial use permit application that contains at a minimum the following:
a)All raw data and analytical results gathered in accordance with the initial beneficial use byproduct characterization demonstration.
Raw data provided? YES NOIf yes, attachment title or page number here:
b)A summary table of all the raw data and the data analysis included in a computerized database or electronic spreadsheet.
Summary table provided? YES NOIf yes, attachment title or page number here:
Data analysis provided? YES NO
If yes, attachment title or page number here:
c)The analytical report containing enough detailed information so that the reported statistical analyses are reproducible.
Analytical report provided? YES NOIf yes, attachment title or page number here:
d)A description of the statistical or empirical data evaluation methods to determine the representative average properties of the beneficial use byproduct. If using US EPA’s ProUCL, please provide the reports generated from calculating the 95% UCL.
If the above information is provided in an attachment, provide attachment title or page number here:e)A data validation report performed by a person not employed by the laboratory performing the initial beneficial use byproduct characterization demonstration.
Data validation report provided? YES NOIf yes, attachment title or page number here:
25.Additional Attachments
The following are included in this application package (check appropriate box(es) and the attachment title or page number):Detail Plans: / Management Plan:
Soil Evaluation Form: / Engineering Report:
Hydrogeologic Site Investigation Report: / Engineering Specifications:
Site Evaluation Form: / Sewer Authority Letter:
Other (describe): / Antidegredation Addendum:
Narrative Plans:
26.Compliance demonstration. The applicant is required to develop and submit a proposed compliance demonstration with the individual beneficial use permit application.
Please describe the sampling and analysis procedures that will be used when performing the annual compliance demonstration and include all beneficial use byproducts that the applicant is seeking to beneficially use under this individual beneficial use permit application. The proposed compliance demonstration shall include all components of the initial byproduct characterization. If the compliance demonstration proposes different sampling and analysis than the initial beneficial use byproduct characterization, provide the explanation for the change including at a minimum the following:a)An explanation of any changes made to the list of constituents of concern.
b)An explanation of any changes of the analytical method selected and of the appropriateness of theselected analytical method.
c)An explanation of any changes to the sampling strategy to characterize the beneficial use byproductby volume or as generated through time.
d)An explanation of any changes to the sample handling techniques or shipping procedures.
e)An explanation of any changes to the sampling strategy followed to obtain representative samples.
f)An explanation of any changes of the sampling strategy including locations and number of samples.
If the above information is provided in an attachment, provide attachment title or page number here:
The applicant may ask Ohio EPA to consider drafting the individual beneficial use permit that does not require an annual compliance demonstration. For example, if all of the sampling and analysis of the beneficial use byproduct has been conducted prior to submitting the individual beneficial use permit application, it may not be necessary to require an annual compliance demonstration.
If the above request is provided in an attachment, provide attachment title or page number here:
27.Submittals
a)Please submit two complete copies of this application in either electronic format (preferred) or hard copy (this minimizes time the Agency spends distributing copies for internal use); and
b)Fee check for $350.00 payable to “Treasurer, State of Ohio.”
28.Signature of Applicant: (see OAC Rule 3745-599-25)
"By signing this document I hereby certify that all statements and all assertions of fact made in the document to the best of my knowledge and belief are true and accurate, include all required information, and comply fully with applicable rules."
Typed Name: /Title:
Signature: /Date:
/ //Beneficial Use Individual Permit Application FormLast Modified 02/18
[1]For more than two generators, attach additional pages to include each generator’s information.