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Draft Form 394 - Alabama Department of Environmental Management

Draft Form 394 - Alabama Department of Environmental Management

Draft Form 394 - Alabama Department of Environmental

NOTICE OF INTENT – GENERAL PERMIT NUMBER ALG340000 (ADEM Form 394 ______) DISCHARGES ASSOCIATED WITH PETROLEUM PRODUCTS CONSISTING OF STORM WATER, HYDROSTATIC TEST WATER, AND GROUNDWATER RESULTING FROM THE STORAGE, HANDLING, TRANSPORTATION, INVESTIGATION OF POTENTIAL CONTAMINATION, OR OTHER OPERATIONS INVOLVING PETROLEUM AND EXTERIOR VEHICLE WASHWATER ASSOCIATED WITH PETROLEUM AND ITS DERIVATIVES Mail to: Alabama Department of Environmental Management Industrial General Permit Section Industrial/Municipal Branch Water Division Post Office Box 301463 Montgomery, Alabama 36130-1463 FOR OFFICE USE ONLY NPDES PERMIT NUMBER FACILITY NUMBER ANSWER ALL QUESTIONS IN APPLICABLE SECTIONS. PLEASE MARK THE “NOT APPLICABLE” BOX IF A SECTION IS NOT APPLICABLE. INCOMPLETE OR WRONG ANSWERS COULD RESULT IN MORE STRINGENT PERMIT REQUIREMENTS. IF SPACE IS INSUFFICIENT TO ADDRESS ANY ITEM BELOW PLEASE CONTINUE ANSWER ON AN ATTACHED SHEET OF PAPER. A. Name of Facility to be shown on Permit: Name of permittee if different from above: B. Mailing Address of Facility: – PO Box or Street Route FACILITY IDENTIFICATION INFORMATION City, State and Zip Code C. Location (STREET ADDRESS) of Facility: City, County: D. Provide the latitudinal and longitudinal coordinates of the facility location. (Front Gate): Latitude ( ) ° ( ) ‘ ( ) “ N Longitude ( ) ° ( ) ‘ ( ) “ W E. Facility Contact Person and Title: Telephone Number: ( ) F. Standard Industrial Code (SIC) (Names and Codes): G. Description of industrial activity and land use at the facility: H. Check the type of discharge at your facility and complete the applicable sections associated with the type checked: [ ] Groundwater and/or storm water incidental to groundwater cleanup operations which has been contaminated with automotive gasoline, aviation fuel ,jet fuel, or diesel fuel [ ] Storm water from petroleum storage and fueling areas [ ] Exterior vehicle and equipment wash water [ ] Hydrostatic test water generated on site. I. Please indicate which, if any, of the discharges in H. are combined. __________________________________________________________________ ADEM Form 394 _______m Page 1 of 8

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