3800-PM-BCW0093b
NOI
1/2017
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER
PAG-04
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
GENERAL PERMIT FOR DISCHARGES FROM
SMALL FLOW TREATMENT FACILITIES (SFTFs)
NOTICE OF INTENT (NOI)
Before completing this form, read the step-by-step instructions provided in this application package.
Client ID#
Site ID#
Facility ID#
Related ID#s (If Known)
APS ID#
Auth ID#
DEP USE ONLY
Date Received & General Notes
PAG
PDG?
GENERAL INFORMATION
New Facility
Type of Facility:
Existing Facility
Expansion of Existing Facility
SRSTP
Other SFTF (non-SRSTP)
If this facility is currently operating under an NPDES Permit, identify the permit number:
PA
Is the receiving water(s) designated for High Quality (HQ) or Exceptional Value (EV)?
YES
NO
NOTE: If the facility discharges to HQ or EV waters or is designed to treat sewage flows exceeding 2,000 gallons per
day, the PAG-04 General Permit cannot be used.
CLIENT/OPERATOR INFORMATION
DEP Client ID#
Client Type/Code
Organization Name or Registered Fictitious Name
Employer ID# (EIN)
Dun & Bradstreet ID#
Individual Last Name
First Name
MI
Suffix
SSN
Additional Individual Last Name
First Name
MI
Suffix
SSN
Mailing Address Line 1
Mailing Address Line 2
Address Last Line – City
State
ZIP+4
Country
Client Contact Last Name
First Name
MI
Suffix
Client Contact Title
Phone
Ext
Email Address
FAX
SITE INFORMATION
DEP Site ID#
Site Name
Number of Employees Present at Site
Description of Site
County Name
Municipality Name
City
-1-
Boro
Twp
State
3800-PM-BCW0093b
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County Name
Municipality Name
City
Site Location Address Line 1
Site Location Address Line 2
Site Location City
State
Boro
Twp
State
ZIP+4
Detailed Written Directions to Site
Site Contact Last Name
First Name
MI
Suffix
Site Contact Title
Site Contact Firm
Mailing Address Line 1
Mailing Address Line 2
Address Last Line – City
State
Phone
Ext
FAX
ZIP+4
Email Address
SIC Code(s) (List All That Apply)
NAICS Code(s)
Site-to-Client Relationship
FACILITY INFORMATION
Attach a facility map or sketch indicating relevant features including locations of structure(s), treatment system(s), and
discharge point(s) (outfalls). Also attach a topographic map that extends at least one mile beyond the property boundary. If a
topographic map is not available, use a map that depicts surface waters within the one-mile boundary.
Provide the latitude and longitude coordinates at the center of the facility.
USGS Quadrangle:
Latitude
Degrees
Minutes
Longitude
Seconds
Degrees
Minutes
Seconds
Identify all outfalls and provide the information requested in the tables below.
Outfall No.
Outfall No.
Latitude
Degrees
Minutes
Annual Average Flow (GPD)
Actual
Design
Longitude
Seconds
Degrees
Receiving Water Name
-2-
Minutes
Seconds
Designated or Existing Use
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Provide a detailed description of the proposed SFTF (i.e., number of tanks, type of treatment process, type of disinfection and
sand filters, etc.).
Existing Permits – Identify all existing environmental permits issued by DEP or EPA for this facility.
Type of Permit
Permit No.
Date Issued
Issued By
COMPLIANCE HISTORY
Was/Is the facility owner or operator in violation of any DEP regulation, permit, order
or schedule of compliance at this or any other facility?
YES
NO
If "Yes," list each permit, order or schedule of compliance and provide current compliance status. Use additional sheets to
provide information on all permits.
Permit Program:
Permit No.:
Brief Description of Non-Compliance:
Steps Taken to Achieve Compliance:
Current Compliance Status:
Date(s) Compliance Achieved:
In Compliance
Non-Compliance
CERTIFICATION
I certify under penalty of law and subject to the penalties of 18 Pa. C.S. Section 4904 (relating to unsworn falsification to
authorities) that this document and all attachments were prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gathered and evaluated 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 submitted is, to the best of my knowledge and belief, true, accurate, and complete. I further acknowledge that
the facility and operator described herein is eligible for coverage under DEP’s General Permit. I am aware that there are
significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Name (type or print legibly)
Official Title
Signature
Date Signed
-3-