CITRUS PACKINGHOUSE WASH WATER GENERAL PERMIT



NOTIFICATION FORMTO USE THE GENERAL PERMIT FOR SAND AND LIMESTONE MINES (RULE 62-660.804, F.A.C.)PART I – INSTRUCTIONSThis form is to be completed and submitted to the Department along with the information specified at least 30 days before use of this general permit. The type of facility that qualifies for a general permit and the conditions of the permit are specified in Rule 62-660.804, F.A.C. You should familiarize yourself with this rule before completing this form.PLEASE NOTE: THE PERMITTEE IS RESPONSIBLE FOR COMPLYING WITH ALL OF THE PROVISIONS OF RULE 62-660.804, F.A.C. IF THE CONDITIONS OF THE RULE ARE VIOLATED THE GENERAL PERMIT CAN BE REVOKED AND THE OPERATOR MAY BE SUBJECT TO PENALTIES UNDER RULE 62-4.540, F.A.C., AND OTHER DEPARTMENT RULES.Please print or type information in the appropriate areas below. Attach additional information on separate sheet(s) as necessary. Submit this completed form and supporting documentation and the $500.00 application fee to the industrial wastewater program at the local DEP office. Electronic submittal is preferred and may be available at the DEP Business Portal . To locate a local DEP office, go to: . Checks should be payable to the Florida Department of Environmental Protection. DEP will not process this form without the appropriate fee. If an item is not applicable to your project, indicate “NA” in the appropriate space provided.PART II – FACILITY STATUS A. Is this notification of a new request for General Permit coverage or a renewal of an existing permit in effect as of January 2015? New (STOP, see Note* below) Renewal of GP (See question II.B. below)Does your facility hold a permit issued under Part IV of Chapter 373, F.S.? Yes (STOP see Note* below) No (Complete all parts of this form)*Note: Coverage under this general permit applies to existing sand and limestone mines which have coverage under this rule as of January 2015. If you hold a current Environmental Resource Permit issued under Part IV of Chapter 373, F.S., you do not need to obtain a separate permit under this rule. PART III – GENERAL INFORMATIONPERMIT NUMBER (if known):DEP Permit No.:NAME OF FACILITY:Facility Name:FACILITY CONTACT:1. Name and Title (Last, first, & title)2. Phone (area code & no.)3. Email Address:FACILITY MAILING ADDRESS:1. Street or P.O. Box:2. City or Town:State:Zip Code:FACILITY LOCATION:1. Street, Route or Other Specific Identifier: 2. County Name:3. County Code (if known):4. City or Town:5. State:6. Zip Code:7. Latitude: _____ _____ _____ 8. Longitude: _____ _____ _____ OPERATOR INFORMATION:The operator of the facility is the legal entity which controls the facility’s operation. Provide the name, as it is legally referred to, of the person, firm, public organization, or any other entity which operates the facility and the additional information requested below:Name:2. Is the name in F.1. the owner? Yes No (complete part G)3. Phone No.:4. Email Address:5. Street or P.O. Box:6. City or Town:7. State:8. Zip CodeOWNER INFORMATION:The owner of the facility is the legal entity which has ownership of the facility. Provide the name, as it is legally referred to, of the person, firm, public organization, or any other entity which owns the facility and the additional information requested below:Name:Company:3. Phone No.:4. Email Address:5. Street or P.O. Box:6. City or Town:7. State:8. Zip CodeMAP: Submit with this notification form a U.S. Geological Survey Quadrangle topographic map showing the location of the existing and proposed areas to be mined extending to at least one mile beyond the property boundaries. Show all public and private potable water supply wells and sink holes within one-half mile of the site. Include all springs, rivers and other surface water bodies (including wetlands) in the map area.PART IV – SITE INFORMATIONSITE PLAN:□ Check this box if all property boundaries, locations of surface water storage areas for storm events and emergency overflows, existing and proposed areas to be mined, existing and proposed process wastewater storage areas, and proximity to surrounding water bodies have not changed since the last renewal. If changes have occurred, submit with this notification form a scaled site plan(s) of the site showing the following:property boundaries;general location of surface water storage areas for storm events up to a 25-year, 24-hour storm event and emergency overflows;existing and proposed areas to be mined;existing and proposed process wastewater storage areas; and, surrounding water bodies. FACILITY INFORMATION:□ Check this box if all material mined at the facility, total area of mine and processing plant and chemicals added to waters for transporting, washing or processing have not changed since the last renewal. If changes have occurred, submit the following updated information:1) Material mined at the facility: □ Sand (excluding heavy minerals) □ Limestone □ Shell □ Coquina 2) Attach letter of exemption from the ground water monitoring plan requirements of 62-520.600(3). (Attach copy of previous exemption if information has not changed since last renewal) 3) Total area of mine and processing plant: _________ acres4) List of all chemicals added to waters used for transporting, washing, or processing of the sand or limestone at the facility. All chemicals must have been demonstrated as to not adversely affect human health or aquatic life: __________________________________________________________________________________________________________________________________________________________________________________________PART V – STATEMENT BY PERMITTEEThe undersigned owner or his authorized representative* certify under penalty of law that this document and all attachments were prepared under my direction or supervision and 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 fine and imprisonment for knowing violations. I agree to maintain and operate the facility as described above and to notify the Department promptly if there are any significant deviations from the design or plans submitted with this notice. _________________________________________________________________________________ Name & Official Title (type or print) 1 Signature___________________________________________ __________________________ Telephone No. Date signed___________________________________________ Email Address*Attach a letter of authorizationPART VI – CERTIFICATION BY PROFESSIONAL ENGINEERThis is to certify that the design calculation for sizing the containment and recycle system to contain all process wastewater and the runoff from a 25-year, 24-hour storm event have been prepared or examined by me and found to be in conformity with sound engineering principles. All earthen dams storing process wastewater and runoff above grade are constructed and maintained in accordance with sound engineering practices. This further certifies that the BMP plan for this facility has also been prepared or examined by me and is determined to be in conformity with sound engineering principles. The BMP plan is adequate to prevent and control spills and promote containment for all pollutants used, stored, or transported at the facility. _____________________________________ ___________________________________________Name (please type or print) Company Name_____________________________________ Address: ____________________________________Signature _________________________________________________________________________________ Date _________________________________________________________________________________ Florida Registration No. ____________________________________________ Telephone No.(Affix Seal) ____________________________________________ Email Address ................
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