Bureau of Point and Non-Point Source Management

3800-FM-BPNPSM0302 3/2012

3800-FM-BPNPSM0302 3/2012COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT

Request for Time Extension to Achieve WQBEL
(Two copies are to be submitted.)
A. / Basic Discharge Information / Date Prepared:
1. / Permittee Name and Mailing Address:
2. / Name of Discharging Facility: / Municipality/County
3. / Stream Which Receives Discharge:
4. / NPDES Permit Number: / Date Issued:
5. / Time extension being requested for the following outfalls and parameters:
Outfall Number / Source(s) of Wastewater / Pollutant / Applicable Effluent Limit / Permit Page No.
B. / Information Needed to Determine Eligibility Requirements (see 25 Pa. Code §95.4 of DEP’s Rules and Regulations)
1. / Cutoff Date (25 Pa. Code §95.4(a)(1))
Indicate the date on which discharge of the pollutant(s) in question began.
2. / New Source (25 Pa. Code §95.4(b)(1))
a. / Has EPA promulgated effluent limitation guideline regulations which include “Standards of Performance for New Sources” (NSPS) for the wastewater discharge(s) in question? (Not Applicable for Municipal Dischargers.)
Yes No
b. / If so, identify the NSPS regulation and its date of promulgation.
c. / When did “construction” of the facility which is the source of the wastewater discharge(s) begin?
3. / Toxic Pollutant Effluent Standards or Prohibitions (25 Pa. Code § 95.4 (b)(2))
a. / Has EPA promulgated a toxic pollutant “effluent standard or prohibition” under Section 307 of the CWA which applies to the wastewater discharge(s) and pollutant(s) in question?
Yes No
b. / If so, identify the effluent standard or prohibition and the date of promulgation, the type of wastewater and the applicable pollutants.
4. / Compliance History (25 Pa. Code §95.4(b)(3))
Explain below, and/or attach a summary, the discharger’s history of compliance with regard to applicable requirements of DEP during the past 5 years.
C. / Other Prerequisites
1. / Installation of BCT/BAT/NSPS (25 Pa. Code §95.4(a)(2)) (Not Applicable for Municipal Dischargers)
a. / Has EPA promulgated ELG regulations which define BCT, BAT, and/or NSPS for the wastewater discharge(s) and pollutant(s) in question?
Yes No
b. / If so, identify BCT/BAT/NSPS regulation and its date of promulgation.
c. / Has the applicant installed facilities capable of meeting BCT/BAT requirements? (Attach explanation if necessary.)
Yes No
2. / Installation of Best Demonstrated Technology (BDT) (25 Pa. Code§95.4(a)(2) and(3))
Attach a description of efforts which have been made or will be made to install BDT for the wastewater and pollutants for which the 25 Pa. Code §95.4 time extension is being requested. Include in this documentation the actual or expected results of:
a. / Full-scale installation and operation of treatment technologies and management practices (include information, where available, on experiences of other similar dischargers).
b. / Pertinent investigations and pilot plant operations carried out by the dischargers which have been used in establishing BDT for the discharger.
3. / Additional Efforts to Achieve WQBEL (25 Pa. Code §95.4(a)(4))
Describe in detail (using attached sheets and by cross-referencing other documents available to DEP) additional efforts which have been made to achieve WQBEL for the discharge(s) and pollutants in question. This discussion should include, but should not be limited to:
a. / Modifying process materials or production methods or both.
b. / Utilizing alternate point of wastewater discharge - including the use of land application of wastewater.
c. / Implementing wastewater management practices such as wastewater recycling, wastewater reuse and good housekeeping.
d. / Conducting research into the application of new or innovative wastewater treatment technologies or management practices (including pilot plant operations of sufficient size and duration to demonstrate adequately the technical feasibility of such treatment technologies or management practices).
4. / Effluent Quality Considered Achievable
a. / Summarize the effluent quality considered achievable with BDT as described under 2. above and through further investigations identified under Step3. above.
b. / Indicate the date(s) on which compliance with such effluent quality will be achieved.

AFFIDAVIT

I certify that I am authorized to make this application and am familiar with the information contained in the application and that to the best of my knowledge and belief such information is true, complete and accurate. (It is an offense under the Pennsylvania Crimes Code to affirm a false statement in documents submitted to DEP.)

Print Name of Personal SigningDate of Submittal

Print Title of Personal Signing

Signature

Contact person in the event DEP requires additional information:

Name:

Address:

Telephone No.:

List of Attachments

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