IOWA DEPARTMENT OF NATURAL RESOURCES
IOWA DEPARTMENT OF NATURAL RESOURCES NPDES PERMIT APPLICATION
FORM 7 – LIVESTOCK TRUCK WASH LAND APPLICATION PERMIT
| |
| |NAME |STREET ADDRESS |
|COMPANY | | |
|INFORMATION | | |
| | | |
| |TELEPHONE |CITY |STATE |ZIP CODE |
| | | | | |
| |
| |NAME |STREET ADDRESS |
|OWNER | | |
|INFORMATION | | |
| | | |
| |TELEPHONE |CITY |STATE |ZIP CODE |
| | | | | |
| |
| |NAME |TITLE |MAILING ADDRESS |
|CONTACT | | | |
|PERSON | | | |
| | | | |
| |TELEPHONE |CITY |STATE |ZIP CODE |
| | | | | |
| |
|TRUCK |COUNTY: |
|WASH | |
|LOCATION | |
| |SECTION |TOWNSHIP |RANGE |
| | | | |
| |
| |If wastewater will be land applied how will it be applied (center pivot, traveling gun, mobile equipment, etc.)? Will wastewater be surface applied|
|LAND |or injected? |
|APPLICATION | |
|METHOD | |
| | |
| | |
|LAND |If wastewater is land applied by someone other than the person that generates the wastewater, provide the information for each person who land |
|APPLICATION |applies the wastewater: |
|BY OTHER | |
|ENTITY | |
| |NAME |STREET ADDRESS |
| | | |
| |TELEPHONE |CITY |STATE |ZIP CODE |
| | | | | | |
| |Provide the following information for each disposal site. Attach additional sheets if necessary. |
|LAND | |
|APPLICATION | |
|SITE | |
|INFORMATION | |
| |SITE NUMBER 1 |
| | |COUNTY: |
| | |LEGAL DESCRIPTION: |
| | |QUARTER SECTION |QUARTER SECTION |SECTION |TOWNSHIP |RANGE |
| | | | | | | |
| | |NUMBER OF ACRES (for land application sites): |
| | |NAME OF PROPERTY OWNER: |
| | | |
| | |
| |SITE NUMBER 2 |
| | |COUNTY: |
| | |LEGAL DESCRIPTION: |
| | |QUARTER SECTION |QUARTER SECTION |SECTION |TOWNSHIP |RANGE |
| | | | | | | |
| | |NUMBER OF ACRES (for land application sites): |
| | |NAME OF PROPERTY OWNER: |
| | |
|LOCATION |Provide a map or photo showing the location of the truck wash, the storage structure and each land application site. |
|MAP | |
| | |
|CERTIFICATION: ALL APPLICANTS MUST COMPLETE THE FOLLOWING CERTIFICATION. |
|I certify under penalty of law that this document and each of the forms indicated above as being part of this application were prepared under my direct supervision in |
|accordance with a system designed to assure 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, the information 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. |
|NAME: |SIGNATURE: | |
|TELEPHONE NUMBER: |DATE: | |
|Upon request you must submit any other information necessary to assess wastewater treatment practices or identify appropriate permitting requirements. | |
| | | |
| |SEND COMPLETED APPLICATION FORMS TO: IOWA DEPARTMENT OF NATURAL RESOURCES | |
| |NPDES SECTION | |
| |502 EAST 9TH STREET | |
| |DES MOINES, IA 50319 | |
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