3510-2C NPDES Application Form 2C

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United States
Environmental Protection Agency

Office of Water
Washington, D.C.

OMB No. 2040-0004
Expires MM/DD/YYYY

Water Permits Division

Application Form 2C
Existing Manufacturing,
Commercial, Mining, and
Silvicultural Operations
NPDES Permitting Program

Note: Complete this form and Form 1 if your facility is an existing manufacturing, commercial, mining,
or silvicultural facility that currently discharges process wastewater.

Paperwork Reduction Act Notice
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C.
3501 et seq. (OMB Control No. 2040-0004). Responses to this collection of information are mandatory
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Send comments on the Agency’s need for this information, the accuracy of the provided burden
estimates and any suggested methods for minimizing respondent burden to the Regulatory Support
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completed form to this address.

FORM 2C—INSTRUCTIONS
permitting authority. See Exhibit 1–1 of Form 1’s “General
Instructions” for contact information. Additionally, for Tables A
through E, provide the applicable outfall number at the top of
each page.
Section 1. Outfall Location
Item 1.1. Identify each of the facility’s outfall structures by
number. For each outfall, specify the latitude and longitude to
the nearest 15 seconds or equivalent decimal degrees (e.g.,
38.893829, -77.029289) and name of the receiving water. The
application form provides reporting space for three outfalls. If
your facility has more than this number, attach additional sheets
as necessary. The location of each outfall (i.e., where the
coordinates are collected) shall be the point where the
discharge is released into a water of the United States. Latitude
and longitude coordinates may be obtained in a variety of ways,
including use of hand held devices (e.g., a GPS enabled
smartphone), internet mapping tools, geographic information
systems (e.g., ArcView), or paper maps from trusted sources
(e.g., U.S. Geological Survey or USGS). For further guidance,
refer to http://www.epa.gov/geospatial/latitudelongitude-datastandard.
Section 2. Line Drawing
Item 2.1. Attach a line drawing showing water flow through your
facility, from intake to discharge. Indicate the sources of intake
water (e.g., city, well, stream, other); operations contributing
wastewater to the effluent including process and production
areas, sanitary flows, cooling water, and stormwater runoff; and
treatment units labeled to correspond to the more detailed
descriptions under Section 3. You may group similar operations
into a single unit.
Construct a water balance on the line drawing by showing
average flows (specify units) between intakes, operations,
treatment units, and outfalls. Show all significant losses of water
to products, the atmosphere, and discharge. You should use
actual measurements wherever available; otherwise use your
best estimate. If you cannot determine a water balance for your
activities (such as mining activities), provide a pictorial
description of the nature and amount of any sources of water
and any collection and treatment measures. An example of an
acceptable line drawing is provided in Exhibit 2C–1 at the end of
these instructions.
Section 3. Average Flows and Treatment
Item 3.1. For each outfall identified under Item 1.1, provide the
following information: (1) all processes, operations, or
production areas that contribute wastewater to the effluent for
the outfall, including process wastewater, sanitary wastewater,
cooling water, and stormwater runoff; (2) average flow of
wastewater contributed by each operation in million gallons per
day (mgd); (3) a description of the treatment unit (including size
of each treatment unit, flow rate through each treatment unit,
retention time, etc.); (4) the applicable treatment code(s) from
Exhibit 2C–2 (see end of instructions); and (5) the ultimate
disposal of any solid or fluid wastes that are not discharged to
the receiving water. You may describe processes, operations, or
production areas in general terms (e.g., “dye-making reactor” or
“distillation tower”). You may estimate the average flow of point
sources composed of stormwater; however, you must indicate

General Instructions
Who Must Complete Form 2C?
You must complete Form 2C if you answered “Yes” to Item 1.2.2
on Form 1—that is, if you are an existing manufacturing,
commercial, mining, or silvicultural facility that currently
discharges process wastewater.
Where to File Your Completed Form
Submit your completed application package (Forms 1 and 2C)
to your National Pollutant Discharge Elimination System
(NPDES) permitting authority. Consult Exhibit 1–1 of Form 1’s
“General Instructions” to identify your NPDES permitting
authority.
Public Availability of Submitted Information
The U.S. Environmental Protection Agency (EPA) will make
information from NPDES permit application forms available to
the public for inspection and copying upon request. You may not
claim any information on Form 2C (or related attachments) as
confidential.
You may make a claim of confidentiality for any information that
you submit to EPA that goes beyond the information required by
Form 2C. Note that NPDES authorities will deny claims for
treating any effluent data as confidential. If you do not assert a
claim of confidentiality at the time you submit your information to
the NPDES permitting authority, EPA may make the information
available to the public without further notice to you. EPA will
handle claims of confidentiality in accordance with its business
confidentiality regulations at Part 2 of Title 40 of the Code of
Federal Regulations (CFR).
Completion of Forms
Print or type in the specified areas only. If you do not have
enough space on the form to answer a question, you may
continue on additional sheets, as necessary, using a format
consistent with the form.
Do not leave any response areas blank unless the form directs
you to skip them. If the form directs you to respond to an item
that does not apply to your facility or activity, enter “NA” for “not
applicable” to show that you considered the item and
determined a response was not necessary for your facility.
The NPDES permitting authority will consider your application
complete when it and any supplementary material are received
and completed according to the authority’s satisfaction. The
NPDES permitting authority will judge the completeness of any
application independently of the status of any other permit
application or permit for the same facility or activity.
Definitions
The legal definitions of all key terms used in these instructions
and Form 2C are in the “Glossary” at the end of the “General
Instructions” in Form 1.
Line-by-Line Instructions
EPA Identification Number, NPDES Permit Number, Facility
Name, and Outfall Number
Provide your EPA Identification Number from the Facility
Registry Service, NPDES permit number, and facility name at
the top of each page of Form 2C and any attachments. If you do
not know your EPA Identification Number, contact your NPDES
2C-1

FORM 2C—INSTRUCTIONS (CONTINUED)
the basis of the rainfall event and the method of estimation. Add
additional sheets as necessary.
Item 3.2. Answer whether you are applying for an NPDES
permit to operate a privately owned treatment works. If yes,
continue to Item 3.3. If no, skip to Section 4.
Item 3.3. Attach a list to your application that includes the
identity of each user of the treatment works, then answer “Yes”
to Item 3.3. For the purpose of this item, the term “user” means
any entity other than the applicant that contributes wastewater
to the treatment works.
Section 4. Intermittent Flows
Item 4.1. Answer “Yes” or “No” to indicate whether any of the
discharges you described in Sections 1 and 3 of Form 2C are
intermittent or seasonal, except for stormwater runoff, spillage,
or leaks. An intermittent discharge is one that is not continuous.
A continuous discharge is one that occurs without interruption
during the operating hours of the facility, except for infrequent
shutdowns for maintenance, process changes, or other similar
activities. A discharge is seasonal if it occurs only during certain
parts of the year. If yes, continue to Item 4.2. If no, skip to
Section 5.
Item 4.2. By relevant outfall number, identify each operation that
has intermittent or seasonal discharges. Indicate the average
frequency (days per week and months per year), the long-term
average and maximum daily flow rates in mgd, and the duration
of the intermittent or seasonal discharges. Base your answers
on actual data if available. Otherwise, provide your best
estimate. Report the average of all daily values measured
during days when the discharge occurred for “Long-Term
Average,” and report the highest daily value for “Maximum
Daily.”
Section 5. Production
Item 5.1. Indicate whether any effluent limitation guidelines
(ELGs) promulgated under Section 304 of the Clean Water Act
(CWA) apply to your facility. If yes, continue to Item 5.2. If no,
skip to Section 6. All ELGs promulgated by EPA appear in the
Federal Register and are published annually in 40 CFR
Subchapter N. See also www.epa.gov/eg. An ELG applies if you
have any operations contributing process wastewater in any
subcategory covered by a Best Practicable Control Technology
Currently Available (BPT), Best Conventional Pollutant Control
Technology (BCT), or Best Available Technology Economically
Achievable (BAT) guideline. If you are unsure whether you are
covered by a promulgated ELG, consult your NPDES permitting
authority (see Exhibit 1–1 of the “General Instructions” of Form
1). You must check “Yes” if an applicable ELG has been
promulgated, even if the ELG is being contested in court. If you
believe that a promulgated ELG has been remanded for
reconsideration by a court and does not apply to your
operations, you may answer “No” to Item 5.1 and skip to Section
6.
Item 5.2. Complete Item 5.2 by indicating the applicable ELG
category, ELG subcategory, and corresponding regulatory
citation. See the example below.
Item 5.3. Indicate if the limitations in the applicable ELGs are
expressed in terms of production or other measure of operation.
An ELG is expressed in terms of production if it is expressed as
mass of pollutant per operational parameter (e.g., “pounds of

Applicable ELGs

biological oxygen demand per cubic foot of logs from which bark
is removed” or “pounds of total suspended solids per megawatt
hour of electrical energy consumed by smelting furnace”). An
5.2

ELG
Category
Pulp, Paper,
and
Paperboard
Point Source
Category

ELG
Subcategory
Secondary
Fiber NonDeink
Subcategory

Regulatory
Citation
40 CFR 430,
Subpart J

example of an ELG not expressed in terms of a measure of
operation is one that limits the concentration of pollutants. If yes,
continue to Item 5.4. If no, skip to Section 6.
Item 5.4. Indicate the operations, products, or materials
produced at the facility for each outfall. For each operation,
product, or material produced, denote the quantity produced per
day using the measurement units specified in the applicable
ELG. The NPDES permitting authority will use the production
information to apply ELGs to your facility. You may not claim
that the production information you submit is confidential. You
do not need to indicate how you calculated the reported
information. The production figures provided must be based on
a reasonable measure of actual daily production, not on design
capacity or on predictions of future operations.
Item 5.5. Indicate if you are requesting alternative limits based
on an anticipated increase in actual production during the next
permit term. To obtain alternate limits, 40 CFR 122.45(b)(2)(ii)
requires you to define your maximum production capability and
demonstrate to the NPDES permitting authority that your actual
production is substantially below maximum production capability
and that there is a reasonable potential for an increase above
actual production during the duration of the permit. Note that
you are not being asked to submit this information at this time.
Contact your NPDES permitting authority to determine the
specifics of what you should provide and when.
Section 6. Improvements
Item 6.1. Indicate if you are required by any federal, state, or
local authority to meet an implementation schedule for
constructing, upgrading, or operating wastewater treatment
equipment or practices or any other environmental programs
that could affect the discharges described in your application.
The requirements include, but are not limited to, permit
conditions, administrative enforcement orders, enforcement
compliance schedule letters, stipulations, court orders, and
grant or loan conditions. If yes, continue to Item 6.2. If no, skip
to Item 6.3.
Item 6.2. Briefly identify and describe each applicable project
(e.g., consent decree, enforcement order, or permit condition).
For each condition, specify the affected outfall number(s), the
source(s) of the discharge, the projected final compliance date,
and the required final compliance date.
Item 6.3. OPTIONAL ITEM. If desired, attach descriptions of
any additional water pollution control programs (or other
environmental projects that could affect your discharges) that
are now underway or planned. Indicate in your attachments
whether each program is actually underway or is planned, and
indicate your actual or planned schedule for construction.
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FORM 2C—INSTRUCTIONS (CONTINUED)
General Instructions for Reporting, Sampling, and Analysis
Concentration
ppm = parts per million
mg/L = milligrams per liter
ppb = parts per billion
µg/L = micrograms per liter
MPN = most probable number
per 100 milliliters

Important note: Read these instructions before completing Tables A
through E and Section 7 of Form 2C.
General Items
Complete the applicable tables for each outfall at your facility. Be sure to
note the EPA Identification Number, NPDES permit number, facility
name, and applicable outfall number at the top of each page of the tables
and any associated attachments.
You may report some or all of the required data by attaching separate
sheets of paper instead of completing Tables A through E for each of
your outfalls so long as the sheets contain all of the required information
and are similar in format to Tables A through E. For example, you may be
able to print a report in a compatible format from the data system used in
your GC/MS analysis completed under Table B.
Table A requires you to report at least one analysis for each pollutant
listed. Tables B through D require you to report analytical data in two
ways. For some pollutants, you may be required to check the box in the
“Testing Required” column and test and report the levels of the pollutants
in your discharge whether or not you expect them to be present in your
discharge. For all other pollutants, you must check the box in either the
“Believed Present” or “Believed Absent” columns based on your best
estimate and test for those you believe to be present (with some
exceptions). Base your determination that a pollutant is present in or
absent from your discharge on your knowledge of your raw materials,
maintenance chemicals, intermediate and final products and byproducts,
and any previous analyses known to you of your effluent or similar
effluent. For example, if you manufacture pesticides, you should expect
those pesticides to be present in contaminated stormwater runoff.
If you would expect a pollutant to be present solely because of its
presence in your intake water, you must mark “Believed Present” but you
are not required to analyze for that pollutant. Instead, mark an “X” in the
long-term average value of the “Intake” column; optionally, you may
instead provide intake data.
Reporting of Effluent Data
Report sampling results for all pollutants in Tables A through C as
concentration and total mass, except for flow, temperature, pH, color,
and fecal coliform organisms. If you are reporting quantitative data under
Table D, report concentration only.
Flow, temperature, pH, color, and fecal coliform organisms must be
reported as mgd, degrees Celsius (°C), standard units, color units, and
most probable number per 100 milliliters (MPN/100 mL), respectively.
Use the following abbreviations in the columns requiring “units” in Tables
A through D.
Concentration
ppm = parts per million
mg/L = milligrams per liter
ppb = parts per billion
µg/L = micrograms per liter
MPN = most probable number
per 100 milliliters

Mass
lbs. = pounds
ton = tons (English tons)
mg = milligrams
g = grams
kg = kilograms
T = tonnes (metric tons)

Mass
lbs. = pounds
ton = tons (English tons)
mg = milligrams
g = grams
kg = kilograms
T = tonnes (metric tons)

All reporting of values for metals must be in terms of “total recoverable
metal,” unless:
•

An applicable, promulgated ELG specifies the limitation for the
metal in dissolved, valent, or total form;

•

All approved analytical methods for the metal inherently measure
only its dissolved form (e.g., hexavalent chromium); or

•

The permitting authority has determined that in establishing caseby-case limitations it is necessary to express the limitations of the
metal in dissolved, valent, or total form to carry out the provisions
of the CWA.

Note that you are not required to complete the “Maximum Monthly
Discharge” and the “Long-Term Average Daily Discharge” columns of
Tables A through C; however, these fields should be completed if data
are available.
If you measure only one daily value, complete the “Maximum Daily
Discharge” columns of the tables and enter “1” in the “Number of
Analyses” columns. The NPDES permitting authority may require
additional analyses to further characterize your discharges.
For composite samples, the daily value is the total mass or average
concentration found in a composite sample taken over the operating
hours of the facility during a 24-hour period. For grab samples, the
daily value is the arithmetic or flow-weighted total mass or average
concentration found in a series of at least four grab samples taken
over the operating hours of the facility during a 24-hour period.
If you measure more than one daily value for a pollutant and those
values are representative of your wastestream, you must report them.
You must describe your method of testing and data analysis.
When an applicant has two or more outfalls with substantially identical
effluents, the NPDES permitting authority may allow the applicant to
test only one outfall and report those quantitative data as applying to
the substantially identical outfall. If the permitting authority grants your
request, attach a separate sheet to the application form identifying the
outfall tested and describing why the other outfall(s) are substantially
identical.
Reporting of Intake Data
You are not required to report data under the “Intake” columns of
Tables A through C unless you wish to demonstrate your eligibility for a
“net” effluent limitation for one or more pollutants in Tables A through C
(i.e., an effluent limitation adjusted by subtracting the average level of
the pollutant(s) present in your intake water). NPDES regulations allow
net limitations only in certain circumstances. To demonstrate your

2C-3

FORM 2C—INSTRUCTIONS (CONTINUED)
General Instructions for Reporting, Sampling, and Analysis Continued
eligibility, under the “Intake” columns report the average of the results of be flow proportional; either the time interval between each aliquot or the
analyses of your intake water and discuss the requirements for a net
volume of each aliquot must be proportional to either the stream flow at
limitation with your NPDES permitting authority. If your water is treated
the time of sampling or the total stream flow since the collection of the
before use, test the water after it has been treated.
previous aliquot.
Sampling
The collection of samples for the reported analyses should be
supervised by a person experienced in performing sampling of industrial
wastewater. You may contact your NPDES permitting authority for
detailed guidance on sampling techniques and for answers to specific
questions. See Exhibit 1–1 of Form 1 for contact information. Any
specific requirements in the applicable analytical methods—for example,
sample containers, sample preservation, holding times, and the
collection of duplicate samples—must be followed.
The time when you sample should be representative of your normal
operation, to the extent feasible, with all processes that contribute
wastewater in normal operation, and with your treatment system
operating properly with no system upsets. Collect samples from the
center of the flow channel, where turbulence is at a maximum, at a site
specified in your present NPDES permit, or at any site adequate for the
collection of a representative sample.

Use of Historical Data
Existing data may be used, if available, in lieu of sampling conducted
solely for the purposes of this application, provided that: all data
requirements are met; sampling was performed, collected, and analyzed
no more than 4.5 years prior to submission; all data are representative
of the discharge; and all available representative data are considered in
the values reported.
Analysis
Except as specified below, all required quantitative data shall be
collected in accordance with sufficiently sensitive analytical methods
approved under 40 CFR 136 or required under 40 CFR Chapter I,
Subchapter N or O. A method is “sufficiently sensitive” when:

Grab samples must be used for pH, temperature, cyanide, total
phenols, residual chlorine, oil and grease, fecal coliform (including E.
coli), and enterococci (previously known as fecal streptococcus at 40
CFR 122.26(d)(2)(iii)(A)(3)), and volatile organic compounds.
For all other pollutants, a 24-hour composite sample, using a minimum
of four grab samples, must be used unless specified otherwise at 40
CFR 136. However, a minimum of one grab sample may be taken for
effluents from holding ponds or other impoundments with a retention
period greater than 24 hours.
For stormwater discharges, a minimum of one to four grab samples
must be taken, depending on the duration of the discharge. One grab
sample must be taken in the first hour (or less) of discharge, with one
more grab sample (up to a minimum of four) taken in each succeeding
hour of discharge for discharges lasting four hours or more.
Except for stormwater discharges, the NPDES permitting authority may
waive composite sampling requirements for any outfall for which you
demonstrate that use of an automatic sampler is infeasible and that the
minimum of four grab samples will be representative of your discharge.
Results of analyses of individual grab samples for any parameter may
be averaged to obtain the daily average. Grab samples that are not
required to be analyzed immediately may be composited in the
laboratory, if the container, preservation, and holding time requirements
are met and if sample integrity is not compromised during compositing.
See Table II at 40 CFR 136.3 for further information.
A grab sample is an individual sample of at least 100 milliliters collected
at a randomly chosen time over a period not exceeding 15 minutes.
A composite sample is a combination of at least eight sample aliquots
of at least 100 milliliters, collected at periodic intervals during the
operating hours of a facility over a 24-hour period. The composite must

Aliquots may be collected manually or automatically. For “GC/MS
Fraction—Volatile Compounds” in Table B, aliquots must be combined
in the laboratory immediately before analysis. Four (rather than eight)
aliquots or grab samples should be collected for this fraction. These four
samples should be collected during actual hours of discharge over a 24hour period and need not be flow proportioned. Only one analysis is
required.

•

The method minimum level (ML) is at or below the level of the
applicable water quality criterion for the measured pollutant or
pollutant parameter.

•

The method ML is above the water quality criterion, but the amount
of the pollutant or pollutant parameter in the facility’s discharge is
high enough that the method detects and quantifies the level of the
pollutant or pollutant parameter in the discharge.

•

The method has the lowest ML of the analytical methods approved
under 40 CFR 136 or required under 40 CFR Chapter I,
Subchapter N or O, for the measured pollutant or pollutant
parameter.

Consistent with 40 CFR 136, you may provide matrix- or sample-specific
MLs rather than the published levels. Further, where you can
demonstrate that, despite a good faith effort to use a method that would
otherwise meet the definition of “sufficiently sensitive,” the analytical
results are not consistent with the quality assurance (QA)/quality control
(QC) specifications for that method, then the NPDES permitting
authority may determine that the method is not performing adequately
and the NPDES permitting authority should select a different method
from the remaining EPA-approved methods that is sufficiently sensitive
consistent with 40 CFR 122.21(e)(3)(i). Where no other EPA-approved
methods exist, you must select a method consistent with 40 CFR
122.21(e)(3)(ii).
When there is no analytical method that has been approved under 40
CFR 136; required under 40 CFR chapter I, subchapter N or O; or
otherwise required by the NPDES permitting authority, you may use any
suitable method but shall provide a description of the method. When
selecting a suitable method, you may consider other factors, such as a
method’s precision, accuracy, or resolution.

2C-4

FORM 2C—INSTRUCTIONS (CONTINUED)

Item 7.3. Test your effluent from each outfall for each pollutant
listed in Table A for which you have not requested a waiver. You
may also conduct optional tests of your intake water for the
Table A pollutants. See the “General Instructions for Reporting,
Sampling, and Analysis” on pages 2C-5 and 2C-6 for further
information.

Section 7. Effluent and Intake Characteristics
Items 7.1 to 7.17. These items require you to collect and report
data for the parameters and pollutants listed in Tables A through
E, located at the end of Form 2C. The instructions for
completing the tables are table-specific in addition to the criteria
for determining who should complete them. In general, the
following conditions apply:
Table
A

Item 7.4 and Table B. This item asks whether any of the
facility’s processes that contribute wastewater fall into one or
more of the primary industry categories listed in Exhibit 2C–3. If
you are applying for a permit for a privately owned treatment
works, determine your testing requirements based on the
industrial categories of your contributors. This is only an
exercise to determine your testing requirements: you are not
giving up your right to challenge your inclusion in the category
determined for testing (e.g., for deciding whether an ELG is
applicable) before your permit is issued. If yes, continue to Item
7.5. If no, skip to Item 7.8.

Pollutants/Parameters
Conventional and nonconventional pollutants

Who Completes?
All applicants from all
outfalls unless a waiver is
obtained from the
NPDES permitting
authority.
B
Toxic metals, cyanide,
Applicants in the primary
total phenols, and
industry categories listed
organic toxic pollutants in Exhibit 2C–3 at the
end of these instructions.
C
Certain conventional
Applicants subject to
and non-conventional
ELGs that limit pollutants
pollutants
directly or indirectly and
applicants who believe
pollutants may be
present in their facilities’
discharge.
D
Certain hazardous
Applicants who believe
substances and
pollutants may be
asbestos
present in their facilities’
discharge.
E
2,3,7,8Applicants who use or
tetrachlorodibenzo-pmanufacture the pollutant
dioxin (2,3,7,8-TCDD)
or believe the pollutant
may be present in their
facilities’ discharge.
Important note: Read the “General Instructions for Reporting,
Sampling, and Analysis” on pages 2C-5 and 2C-6 before
completing Section 7 and Tables A through E.

Complete a separate Table B for each outfall. Section 1 of Table
B lists toxic metals, cyanide, and total phenols. Sections 2
through 5 of Table B list the pollutants in each of the gas
chromatography/mass spectrometry (GC/MS) fractions. Note
that inclusion of total phenols in Section 1 of Table B does not
mean that EPA is classifying the group as toxic pollutants.
Item 7.5. Because you indicated in Item 7.4 that the facility’s
processes contribute wastewater that falls into one or more of
the primary industry categories, check “Testing Required” for all
toxic metals, cyanide, and total phenols in Section 1 of Table B.
Answer “Yes” to Item 7.5 once you have completed this task.
Item 7.6. Because you indicated in Item 7.4 that the facility’s
processes contribute wastewater that falls into one or more of
the primary industry categories, list the primary industry
categories applicable to your facility. Next, review Exhibit 2C–3
to determine whether testing is required and for which GC/MS
fraction(s): volatile compounds, acid compounds, base/neutral
compounds, and pesticides. Check the applicable boxes for
each GC/MS fraction requiring testing.
Item 7.7. For each of the required GC/MS fractions, check
“Testing Required” for each of the pollutants in the required
fraction in Sections 2 through 5 of Table B. Answer “Yes” to Item
7.7 once you have completed this task.
Item 7.8 and Sections 1 through 5 of Table B. For all other
cases (secondary industries, nonprocess wastewater outfalls,
and nonrequired GC/MS fractions) and remaining pollutants,
check “Believed Present” or “Believed Absent” in Sections 1
through 5 of Table B to indicate whether you have reason to
believe that any of the pollutants listed are discharged from your
outfalls. Answer “Yes” to Item 7.8 after you have completed this
step.

Item 7.1 and Table A. All applicants must report at least one
analysis for each conventional and non-conventional pollutant
listed in Table A for each outfall (one table per outfall). This
includes outfalls discharging only noncontact cooling water or
stormwater runoff. However, at your request, the NPDES
permitting authority may waive the requirement to test for one or
more of the listed pollutants for specific outfalls, upon a
determination that available information is adequate to support
issuance of your NPDES permit with less stringent reporting
requirements. You may also request a waiver from your NPDES
permitting authority for one or more of the Table A pollutants for
your industry category or subcategory. Indicate whether you are
requesting a waiver in response to Item 7.1. If yes, continue to
Item 7.2. If no, skip to Item 7.3.

Item 7.9 and Section 1 of Table B. For each pollutant you
know or have reason to believe is present in your discharge
from each applicable outfall in concentrations of 10 parts per
billion (ppb) or greater, you must report quantitative data. For
every pollutant expected to be discharged in concentrations less
than 10 ppb, you must submit quantitative data or briefly
describe the reasons the pollutant is expected to be discharged.
For pollutants in intake water, see the discussion under

Item 7.2. Specify the outfalls for which you are requesting a
waiver or check the appropriate box to indicate that you are
requesting a waiver for some or all pollutants at all outfalls.
Next, indicate in Table A for the applicable outfalls the pollutants
for which the waiver is being requested. Attach your waiver
request and supporting information to your completed Form 2C.
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FORM 2C—INSTRUCTIONS (CONTINUED)
Once you have completed these tasks, answer “Yes” to Item
7.11.
Item 7.12 and Table C. For each outfall (including outfalls
containing only noncontact cooling water or stormwater runoff),
indicate whether you know or have reason to believe that any of
the pollutants listed in Table C are present in your discharge. If
so, mark the box in the “Believed Present” column for each
applicable pollutant. If not, mark the box in the “Believed
Absent” column for each applicable pollutant. Answer “Yes” to
Item 7.12 once you have completed the required task for each
outfall.
Items 7.13 and 7.14 and Table C. You are required to report
quantitative data for any Table C pollutants that are directly
limited in an applicable ELG or are indirectly limited in an
applicable ELG through an expressed limitation on an indicator
(e.g., use of total suspended solids, or TSS, as an indicator to
control the discharge of iron and aluminum). Mark “Not
Applicable” in Item 7.13 if no Table C pollutants are limited
directly or indirectly in an applicable ELG. For all other pollutants
that you marked as “Believed Present,” you must either report
quantitative data or briefly describe the reasons the pollutant is
expected to be discharged.
For pollutants in intake water, see the discussion under
“General Instructions for Reporting, Sampling, and Analysis” on
pages 2C-5 and 2C-6 for further information.
Answer “Yes” to Items 7.13 and 7.14 when you have fully
completed the tasks associated with Table C and Items 7.12
through 7.14 above.
Item 7.15 and Table D. For each outfall, indicate if you believe
that any pollutant listed in Table D is “Believed Present” or
“Believed Absent” in your facility’s effluent. Check the boxes in
the applicable columns in Table D next to each pollutant. For
every pollutant believed present, you must briefly describe the
reasons the pollutant is expected to be discharged and report
any quantitative data you have for that pollutant. Note that you
are not required to perform analytical tests for any of the Table
D pollutants at this time. However, if you have prior test results,
you must report them.
Item 7.16. Answer “Yes” to this Item when you have completed
Table D.

“General Instructions for Reporting, Sampling, and Analysis”
below. Answer “Yes” to Item 7.9 once you have completed
Section 1 of Table B.
Item 7.10. This item asks if you qualify as a “small business.” If
so, you are exempt from submitting quantitative data for the
organic toxic pollutants in Table B (Sections 2 through 5). You
still must indicate, though, whether you believe any of the
pollutants listed in Sections 1 through 5 are present in your
discharge per the Instructions at Item 7.8 above.
You can qualify as a small business in two ways: (1) If your
facility is a coal mine and if your probable total annual
production is less than 100,000 tons per year, you may submit
past production data or estimated future production (such as a
schedule of estimated total production under 30 CFR 795.14(c))
instead of conducting analyses for the organic toxic pollutants.
(2) If your facility is not a coal mine and if your gross total annual
sales for the most recent three years average less than
$100,000 per year (in second quarter 1980 dollars), you may
submit sales data for those years instead of conducting
analyses for the organic toxic pollutants.
The production or sales data must be for the facility that is the
source of the discharge. The data should not be limited to
production or sales for the process or processes that contribute
to the discharge, unless those are the only processes at your
facility.
For sales data, in situations involving intra-corporate transfer of
goods and services, the transfer price per unit should
approximate market prices for those goods and services as
closely as possible. Sales figures for years after 1980 should be
indexed to the second quarter of 1980 by using the gross
national product price deflator (second quarter of 1980 = 100).
This index is available online from the U.S. Department of
Commerce, Bureau of Economic Analysis, at
https://apps.bea.gov/national/pdf/SNTables.pdf.
If you qualify as a small business according to the criteria
above, answer “Yes” to Item 7.10. Check the box at the top of
Table B to show that you are not required to submit quantitative
data for the organic toxic pollutants (Sections 2 through 5 of
Table B), then skip to Item 7.12. Otherwise, answer “No” and
continue to Item 7.11.
Item 7.11 and Sections 2 through 5 of Table B. Unless you
qualify as a small business (see Item 7.10), you must provide
quantitative data for all pollutants for which you marked “Testing
Required” in Sections 2 through 5 of Table B. You must also
provide quantitative data for all pollutants you marked as
“Believed Present” in Sections 2 through 5 of Table B if you
discharge those pollutants in concentrations of 10 ppb or
greater, except for acrolein, acrylonitrile, 2,4-dinitrophenol, and
2-methyl-4,6-dinitrophenol. If you discharge any of the four latter
pollutants in concentrations of 100 ppb or greater, you must
report quantitative data. If you discharge the pollutants in
Sections 2 through 5 of Table B less than these thresholds (i.e.,
<100 ppb for acrolein, acrylonitrile, 2,4-dinitrophenol, and 2methyl-4,6-dinitrophenol and <10 ppb for all others), you must
submit quantitative data or briefly describe the reasons the
pollutant is in your discharge.
For pollutants in intake water, see the discussion under
“General Instructions for Reporting, Sampling, and Analysis” on
pages 2C-5 and 2C-6 for further information.

Under 40 CFR 117.12(a)(2), certain discharges of
hazardous substances (listed in Exhibit 2C–4 at the
end of these instructions) may be exempted from the
requirements of Section 311 of the CWA, which
establishes reporting requirements, civil penalties, and
liability for cleanup costs for spills of oil and hazardous
substances. A discharge of a particular substance can
be exempted if the origin, source, and amount of the
discharged substances are identified in the NPDES
permit application or in the permit, if the permit
contains a requirement for treatment of the discharge,
and if the treatment is in place.
Exemptions are allowed from the requirements of CWA
Section 311. Applications for exemptions must set forth
the following information:

2C-6

FORM 2C—INSTRUCTIONS (CONTINUED)
Section 9. Biological Toxicity Tests
Item 9.1. Indicate if you have any knowledge or reason to
believe that any biological test for acute or chronic toxicity has
been made on any of your discharges or on a receiving water in
relation to your discharge within the last three years. If yes,
continue to Item 9.2. If no, skip to Section 10.
Item 9.2. Identify the tests known to have been performed and
the purposes of each. For each test, check “Yes” or “No” to
indicate if you have submitted the test results to the NPDES
permitting authority and the date the results were submitted.
The NPDES permitting authority may ask you to provide
additional details after reviewing your application.
Section 10. Contract Analyses
Item 10.1. Indicate if any of the analyses reported in Section 7
were performed by a contract laboratory or consulting firm. If
yes, continue to Item 10.2. If no, skip to Section 11.
Item 10.2. Identify each laboratory or firm used in the table
provided. For each, provide the name, address, and phone
number of the laboratory or firm and the pollutants analyzed.
Section 11. Additional Information
Item 11.1. In addition to the information reported on the
application form, the NPDES permitting authority may request
additional information reasonably required to assess the
discharges of the facility and to determine whether to issue an
NPDES permit. The additional information may include
additional quantitative data and bioassays to assess the relative
toxicity of discharges to aquatic life and requirements to
determine the cause of the toxicity. Indicate under Item 11.1
whether the NPDES permitting authority has requested
additional information from you. If yes, continue to Item 11.2. If
no, skip to Section 12.
Item 11.2. List the items requested and attach the required
information to the application.
Section 12. Checklist and Certification Statement
Item 12.1. Review the checklist provided. In Column 1, mark the
sections of Form 2C that you have completed and are
submitting with your application. In Column 2, indicate for each
section whether you are submitting attachments.
Item 12.2. The CWA provides for severe penalties for submitting
false information on this application form. Section 309(c)(2) of
the CWA provides that “Any person who knowingly makes any
false statement, representation, or certification in any
application, ...shall upon conviction, be punished by a fine of no
more than $10,000 or by imprisonment for not more than six
months or both.”
FEDERAL REGULATIONS AT 40 CFR 122.22 REQUIRE THIS
APPLICATION TO BE SIGNED AS FOLLOWS:

1. The substance and the amount of each substance
that may be discharged.
2. The origin and source of the discharge of the
substance.
3. The treatment to be provided for the discharge by:
a. An onsite treatment system separate from any
treatment system treating your normal discharge;
b. A treatment system designed to treat your
normal discharge and that is additionally capable
of treating the amount of the substance identified
under paragraph 1 above; or
c. Any combination of the above.
See 40 CFR 117.12(a)(2) and (c) or contact your
NPDES permitting authority for further information on
exclusions from CWA Section 311.

Item 7.17. Indicate whether:
•

Your facility uses or manufactures 2,4,5-trichlorophenoxy
acetic acid (2,4,5-T); 2-(2,4,5-trichlorophenoxy) propanoic
acid (Silvex, 2,4,5-TP); 2-(2,4,5-trichlorophenoxy) ethyl
2,2-dichloro-propionate (Erbon); 0,0-dimethyl 0-(2,4,5trichlorophenyl) phosphorothioate (Ronnel); 2,4,5,trichlorophenol (TCP); or hexachlorophene (HCP).

•

You know or have reason to believe that 2.3.7,8tetrachlorodibenzo-p-dioxin (TCDD) is or may be present
in an effluent.

If yes, continue to Item 7.18. If no, skip to Section 8.
Item 7.18 and Table E. If you answered “Yes” to Item 7.17, you
must report qualitative data, generated using a screening
procedure not calibrated with analytical standards, for TCDD.
Your screening analyses must be performed using gas
chromatography with an electron capture detector. A TCDD
standard for quantitation is not required. Describe the results of
your screening analysis (e.g., “no measurable baseline
deflection at the retention time of TCDD” or “a measurable peak
within the tolerances of the retention time of TCDD.”) in Table E.
The NPDES permitting authority may require you to perform a
quantitative analysis if you report a positive result.
Answer “Yes” to Item 7.18 when you have completed Table E.
Section 8. Used or Manufactured Toxics
Item 8.1. Indicate if any pollutant listed in Table B is used or
manufactured in your facility as an intermediate or final product
or byproduct. If yes, continue to Item 8.2. If no, skip to Section 9.
Item 8.2. List the applicable toxic pollutants. Note that the
NPDES permitting authority may waive or modify the
requirement if you demonstrate that it would be unduly
burdensome to identify each toxic pollutant and the permitting
authority has adequate information to issue you a permit. You
may not claim this information as confidential. Note that you do
not need to distinguish between use or production of the
pollutants or list amounts.

A.

2C-7

For a corporation, by a responsible corporate officer. For
the purpose of this section, a responsible corporate officer
means: (1) a president, secretary, treasurer, or vicepresident of the corporation in charge of a principal
business function, or any other person who performs
similar policy- or decision-making functions for the
corporation, or (2) the manager of one or more
manufacturing, production, or operating facilities, provided
the manager is authorized to make management decisions
which govern the operation of the regulated facility

FORM 2C—INSTRUCTIONS (CONTINUED)

B.

including having the explicit or implicit duty of making major
capital investment recommendations, and initiating and
directing other comprehensive measures to assure long
term environmental compliance with environmental laws
and regulations; the manager can ensure that the
necessary systems are established or actions taken to
gather complete and accurate information for permit
application requirements; and where authority to sign
documents has been assigned or delegated to the
manager in accordance with corporate procedures.
For a partnership or sole proprietorship, by a general
partner or the proprietor, respectively.

C. For a municipality, state, federal, or other public facility, by
either a principal executive officer or ranking elected
official. For purposes of this section, a principal executive
officer of a federal agency includes: (1) the chief executive
officer of the agency or (2) a senior executive officer having
responsibility for the overall operations of a principal
geographic unit of the agency (e.g., Regional
Administrators of EPA).
END
Submit your completed Form 1, Form 2C, and
all associated attachments
(and any other required NPDES application forms)
to your NPDES permitting authority.

2C-8

FORM 2C—INSTRUCTIONS (CONTINUED)
Exhibit 2C–1. Example Line Drawing

2C-9

FORM 2C—INSTRUCTIONS (CONTINUED)
Exhibit 2C–2. Codes for Treatment Units and Disposal of Wastes Not Discharged
1.

PHYSICAL TREATMENT PROCESSES
1–M ............... Grit removal
1–N................ Microstraining
1–O ............... Mixing
1–P................ Moving bed filters
1–Q ............... Multimedia filtration
1–R................ Rapid sand filtration
1–S................ Reverse osmosis (hyperfiltration)
1–T ................ Screening
1–U................ Sedimentation (settling)
1–V................ Slow sand filtration
1–W............... Solvent extraction
1–X................ Sorption

2.

CHEMICAL TREATMENT PROCESSES
2–G ............... Disinfection (ozone)
2–H................ Disinfection (other)
2–I ................. Electrochemical treatment
2–J ................ Ion exchange
2–K................ Neutralization
2–L ................ Reduction

1–A ................ Ammonia stripping
1–B ................ Dialysis
1–C................ Diatomaceous earth filtration
1–D................ Distillation
1–E ................ Electrodialysis
1–F ................ Evaporation
1–G................ Flocculation
1–H................ Flotation
1–I ................. Foam fractionation
1–J................. Freezing
1–K ................ Gas-phase separation
1–L ................ Grinding (comminutors)

2–A ................ Carbon adsorption
2–B ................ Chemical oxidation
2–C................ Chemical precipitation
2–D................ Coagulation
2–E ................ Dechlorination
2–F ................ Disinfection (chlorine)
3.

BIOLOGICAL TREATMENT PROCESSES
3–E................ Pre-aeration
3–F ................ Spray irrigation/land application
3–G ............... Stabilization ponds
3–H................ Trickling filtration

4.

WASTEWATER DISPOSAL PROCESSES
4–C................ Reuse/recycle of treated effluent
4–D................ Underground injection

3–A ................ Activated sludge
3–B ................ Aerated lagoons
3–C................ Anaerobic treatment
3–D................ Nitrification–denitrification

4–A ................ Discharge to surface water
4–B ................ Ocean discharge to outfall

5.
5–A ................ Aerobic digestion
5–B ................ Anaerobic digestion
5–C................ Belt filtration
5–D................ Centrifugation
5–E ................ Chemical conditioning
5–F ................ Chlorine treatment
5–G................ Composting
5–H................ Drying beds
5–I ................. Elutriation
5–J................. Flotation thickening
5–K ................ Freezing
5–L ................ Gravity thickening

SLUDGE TREATMENT AND DISPOSAL PROCESSES
5–M ............... Heat drying
5–N................ Heat treatment
5–O ............... Incineration
5–P................ Land application
5–Q ............... Landfill
5–R................ Pressure filtration
5–S................ Pyrolysis
5–T ................ Sludge lagoons
5–U................ Vacuum filtration
5–V................ Vibration
5–W............... Wet oxidation

2C-10

FORM 2C—INSTRUCTIONS (CONTINUED)
Exhibit 2C–3. Testing Requirements for Organic Toxic Pollutants Industry Categories*
INDUSTRY CATEGORY

Adhesives and sealants ....................................................
Aluminum forming .............................................................
Auto and other laundries ...................................................
Battery manufacturing .......................................................
Coal mining .......................................................................
Coil coating........................................................................
Copper forming..................................................................
Electric and electronic compounds....................................
Electroplating.....................................................................
Explosives manufacturing .................................................
Foundries ..........................................................................
Gum and wood chemicals (all subparts except D and F)..
Gum and wood chemicals, Subpart D (tall oil rosin)..........
Gum and wood chemicals, Subpart F (rosin-based
derivatives) ........................................................................
Inorganic chemicals manufacturing...................................
Iron and steel manufacturing.............................................
Leather tanning and finishing
Mechanical products manufacturing..................................
Nonferrous metals manufacturing .....................................
Ore mining, Subpart B (base and precious metals) ..........
Organic chemicals manufacturing .....................................
Paint and ink formulation...................................................
Pesticides ..........................................................................
Petroleum refining .............................................................
Pharmaceutical preparations.............................................
Photographic equipment and supplies ..............................
Plastic and synthetic materials manufacturing ..................
Plastic processing .............................................................
Printing and publishing ......................................................
Pulp and paperboard mills.................................................
Rubber processing ............................................................
Soap and detergent manufacturing ...................................
Steam electric power plants ..............................................
Textile mills (except Subpart C, Greige Mills)....................
Timber products processing ..............................................

Volatile

X
X
X
X

X
X
X
X

X
X
X

GC/MS FRACTION†
Acid
Base/Neutral

Pesticide

X
X
X


X
X
X
X
X
X
X
X

X
X
X
X

X
X
X
X
X
X

X

X

X

X



X
X
X
X
X

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

X
X
X
X
X
X
X
X
X

X
X
X

X
X
X
X
X
X
X

X
X
X
X
X

X
X
X

X
X
X

X
X
X
X

X
X





X

X

X



X

X
X




X



X




X






* See note at conclusion of 40 CFR 122, Appendix D (1983) for explanation of effect of suspensions on testing requirements for
primary industry categories.
† The pollutants in each fraction are listed in Table B.
X = Testing is required.
= Testing is not required.

2C-11

FORM 2C—INSTRUCTIONS (CONTINUED)
Exhibit 2C–4. Hazardous Substances
1. Acetaldehyde
2. Acetic acid
3. Acetic anhydride
4. Acetone cyanohydrin
5. Acetyl bromide
6. Acetyl chloride
7. Acrolein
8. Acrylonitrile
9. Adipic acid
10. Aldrin
11. Allyl alcohol
12. Allyl chloride
13. Aluminum sulfate
14. Ammonia
15. Ammonium acetate
16. Ammonium benzoate
17. Ammonium bicarbonate
18. Ammonium bichromate
19. Ammonium bifluoride
20. Ammonium bisulfite
21. Ammonium carbamate
22. Ammonium carbonate
23. Ammonium chloride
24. Ammonium chromate
25. Ammonium citrate
26. Ammonium fluoroborate
27. Ammonium fluoride
28. Ammonium hydroxide
29. Ammonium oxalate
30. Ammonium silicofluoride
31. Ammonium sulfamate
32. Ammonium sulfide
33. Ammonium sulfite
34. Ammonium tartrate
35. Ammonium thiocyanate
36. Ammonium thiosulfate
37. Amyl acetate
38. Aniline
39. Antimony pentachloricle
40. Antimony potassium tartrate
41. Antimony tribromide
42. Antimony trichloride
43. Antimony trifluoride
44. Antimony trioxide
45. Arsenic disulfide
46. Arsenic pentoxide
47. Arsenic trichloride
48. Arsenic trioxide
49. Arsenic trisulfide
50. Barium cyanide
51. Benzene
52. Benzoic acid
53. Benzonitrile
54. Benzoyl chloride
55. Benzyl chloride
56. Beryllium chloride
57. Beryllium fluoride
58. Beryllium nitrate
59. Butylacetate
60. n-butylphthalate
61. Butylamine
62. Butyric acid
63. Cadmium acetate
64. Cadmium bromide
65. Cadmium chloride
66. Calcium arsenate
67. Calcium arsenite
68. Calcium carbide
69. Calcium chromate
70. Calcium cyanide
71. Calcium dodecylbenzenesulfonate
72. Calcium hypochlorite

73. Captan
74. Carbaryl
75. Carbofuran
76. Carbon disulfide
77. Carbon tetrachloride
78. Chlordane
79. Chlorine
80. Chlorobenzene
81. Chloroform
82. Chloropyrifos
83. Chlorosulfonic acid
84. Chromic acetate
85. Chromic acid
86. Chromic sulfate
87. Chromous chloride
88. Cobaltous bromide
89. Cobaltous formate
90. Cobaltous sulfamate
91. Coumaphos
92. Cresol
93. Crotonaldehyde
94. Cupric acetate
95. Cupric acetoarsenite
96. Cupric chloride
97. Cupric nitrate
98. Cupric oxalate
99. Cupric sulfate
100. Cupric sulfate ammoniated
101. Cupric tartrate
102. Cyanogen chloride
103. Cyclohexane
104. 2,4-D acid (2,4-dichlorophenoxyacetic acid)
105. 2,4-D esters (2,4-dichlorophenoxyacetic acid esters)
106. DDT (dichlorodiphenyltrichloroethane)
107. Diazinon
108. Dicamba
109. Dichlobenil
110. Dichlone
111. Dichlorobenzene
112. Dichloropropane
113. Dichloropropene
114. Dichloropropene-dichloproropane mix
115. 2,2-dichloropropionic acid
116. Dichlorvos
117. Dieldrin
118. Diethylamine
119. Dimethylamine
120. Dinitrobenzene
121. Dinitrophenol
122. Dinitrotoluene
123. Diquat
124. Disulfoton
125. Diuron
126. Dodecylbenzesulfonic acid
127. Endosulfan
128. Endrin
129. Epichlorohydrin
130. Ethion
131. Ethylbenzene
132. Ethylenediamine
133. Ethylene dibromide
134. Ethylene dichloride
135. EDTA (ethylene diaminetetracetic acid)
136. Ferric ammonium citrate
137. Ferric ammonium oxalate
138. Ferric chloride
139. Ferric fluoride
140. Ferric nitrate
141. Ferric sulfate
142. Ferrous ammonium sulfate
143. Ferrous chloride

2C-12

144. Ferrous sulfate
145. Formaldehyde
146. Formic acid
147. Fumaric acid
148. Furfural
149. Guthion
150. Heptachlor
151. Hexachlorocyclopentadiene
152. Hydrochloric acid
153. Hydrofluoric acid
154. Hydrogen cyanide
155. Hydrogen sulfide
156. Isoprene
157. Isopropanolamine dodecylbenzenesulfonate
158. Kelthane
159. Kepone
160. Lead acetate
161. Lead arsenate
162. Lead chloride
163. Lead fluoborate
164. Lead fluorite
165. Lead iodide
166. Lead nitrate
167. Lead stearate
168. Lead sulfate
169. Lead sulfide
170. Lead thiocyanate
171. Lindane
172. Lithium chromate
173. Malathion
174. Maleic acid
175. Maleic anhydride
176. Mercaptodimethur
177. Mercuric cyanide
178. Mercuric nitrate
179. Mercuric sulfate
180. Mercuric thiocyanate
181. Mercurous nitrate
182. Methoxychlor
183. Methyl mercaptan
184. Methyl methacrylate
185. Methyl parathion
186. Mevinphos
187. Mexacarbate
188. Monoethylamine
189. Monomethylamine
190. Naled
191. Naphthalene
192. Naphthenic acid
193. Nickel ammonium sulfate
194. Nickel chloride
195. Nickel hydroxide
196. Nickel nitrate
197. Nickel sulfate
198. Nitric acid
199. Nitrobenzene
200. Nitrogen dioxide
201. Nitrophenol
202. Nitrotoluene
203. Paraformaldehyde
204. Parathion
205. Pentachlorophenol
206. Phenol
207. Phosgene
208. Phosphoric acid
209. Phosphorus
210. Phosphorus oxychloride
211. Phosphorus pentasulfide
212. Phosphorus trichloride
213. PCBs (polychlorinated biphenyls)
214. Potassium arsenate

FORM 2C—INSTRUCTIONS (CONTINUED)
215. Potassium arsenite
216. Potassium bichromate
217. Potassium chromate
218. Potassium cyanide
219. Potassium hydroxide
220. Potassium permanganate
221. Propargite
222. Propionic acid
223. Propionic anhydride
224. Propylene oxide
225. Pyrethrins
226. Quinoline
227. Resorcinol
228. Selenium oxide
229. Silver nitrate
230. Sodium
231. Sodium arsenate
232. Sodium arsenite
233. Sodium bichromate
234. Sodium bifluoride
235. Sodium bisulfite
236. Sodium chromate
237. Sodium cyanide
238. Sodium dodecylbenzenesulfonate
239. Sodium fluoride
240. Sodium hydrosulfide
241. Sodium hydroxide
242. Sodium hypochlorite
243. Sodium methylate

Exhibit 2C–4. Hazardous Substances (Continued)
244. Sodium nitrite
245. Sodium phosphate (dibasic)
246. Sodium phosphate (tribasic)
247. Sodium selenite
248. Strontium chromate
249. Strychnine
250. Styrene
251. Sulfuric acid
252. Sulfur monochloride
253. 2,4,5-T acid (2,4,5-trichlorophenoxyacetic acid)
254. 2,4,5-T amines (2,4,5-trichlorophenoxy acetic acid
amines)
255. 2,4,5-T esters (2,4,5-trichlorophenoxy acetic acid
esters)
256. 2,4,5-T salts (2,4,5-trichlorophenoxy acetic acid salts)
257. 2,4,5-TP acid (2,4,5-trichlorophenoxy propanoic acid)
258. 2,4,5-TP acid esters (2,4,5-trichlorophenoxy propanoic
acid esters)
259. TDE (tetrachlorodiphenyl ethane)
260. Tetraethyl lead
261. Tetraethyl pyrophosphate
262. Thallium sulfate
263. Toluene
264. Toxaphene
265. Trichlorofon
266. Trichloroethylene
267. Trichlorophenol
268. Triethanolamine dodecylbenzenesulfonate
269. Triethylamine

2C-13

270. Trimethylamine
271. Uranyl acetate
272. Uranyl nitrate
273. Vanadium penoxide
274. Vanadyl sulfate
275. Vinyl acetate
276. Vinylidene chloride
277. Xylene
278. Xylenol
279. Zinc acetate
280. Zinc ammonium chloride
281. Zinc borate
282. Zinc bromide
283. Zinc carbonate
284. Zinc chloride
285. Zinc cyanide
286. Zinc fluoride
287. Zinc formate
288. Zinc hydrosulfite
289. Zinc nitrate
290. Zinc phenolsulfonate
291. Zinc phosphide
292. Zinc silicofluoride
293. Zinc sulfate
294. Zirconium nitrate
295. Zirconium potassium fluoride
296. Zirconium sulfate
297. Zirconium tetrachloride

EPA Identification Number

NPDES Permit Number

Facility Name

OMB No. 2040-0004
Expires MM/DD/YYYY

U.S. Environmental Protection Agency
Application for NPDES Permit to Discharge Wastewater

Form
2C
NPDES

EXISTING MANUFACTURING, COMMERCIAL, MINING, AND SILVICULTURE OPERATIONS

Outfall Location

SECTION 1. OUTFALL LOCATION (40 CFR 122.21(G)(1))
1.1
Provide information on each of the facility’s outfalls in the table below.
Outfall
Receiving Water Name
Latitude
Number

Longitude

Line
Drawing

SECTION 2. LINE DRAWING (40 CFR 122.21(G)(2))
2.1
Have you attached a line drawing to this application that shows the water flow through your facility with a water
balance? (See instructions for drawing requirements. See Exhibit 2C–1 at end of instructions for example.)



Yes

SECTION 3. AVERAGE FLOWS AND TREATMENT (40 CFR 122.21(G)(3))
3.1
For each outfall identified under Item 1.1, provide average flow and treatment information. Add additional sheets if
necessary.
**Outfall Number** __________
Operations Contributing to Flow
Operation
Average Flow
Average Flows and Treatment

mgd

EPA Form 3510-2C

mgd
mgd
mgd
Treatment Units
Description
Code from
(include size, flow rate through each treatment unit,
Exhibit 2C–2
retention time, etc.)

Final Disposal of Solid or
Liquid Wastes Other Than
by Discharge

Page 1

EPA Identification Number

NPDES Permit Number

3.1
cont.
Operation

Facility Name

**Outfall Number** __________
Operations Contributing to Flow

OMB No. 2040-0004
Expires MM/DD/YYYY

Average Flow
mgd
mgd
mgd
mgd

Average Flows and Treatment Continued

Treatment Units
Description
Code from
(include size, flow rate through each treatment unit,
Exhibit 2C–2
retention time, etc.)

Operation

**Outfall Number** __________
Operations Contributing to Flow

Final Disposal of Solid or
Liquid Wastes Other Than
by Discharge

Average Flow
mgd
mgd
mgd
mgd

Treatment Units
Description
Code from
(include size, flow rate through each treatment unit,
Exhibit 2C–2
retention time, etc.)

System
Users

3.2
3.3

EPA Form 3510-2C

Final Disposal of Solid or
Liquid Wastes Other Than
by Discharge

Are you applying for an NPDES permit to operate a privately owned treatment works?



Yes
 No  SKIP to Section 4.
Have you attached a list that identifies each user of the treatment works?
 Yes

Page 2

EPA Identification Number

NPDES Permit Number

Facility Name

OMB No. 2040-0004
Expires MM/DD/YYYY

SECTION 4. INTERMITTENT FLOWS (40 CFR 122.21(G)(4))
4.1
Except for storm runoff, leaks, or spills, are any discharges described in Sections 1 and 3 intermittent or seasonal?
Yes
 No  SKIP to Section 5.
Provide information on intermittent or seasonal flows for each applicable outfall. Attach additional pages, if
necessary.
Frequency
Flow Rate
Outfall
Operation
Duration
Average
Average
Long-Term
Maximum
Number
(list)
Days/Week
Months/Year
Average
Daily

Intermittent Flows

4.2



days/week

months/year

mgd

mgd

days

days/week

months/year

mgd

mgd

days

days/week

months/year

mgd

mgd

days

days/week

months/year

mgd

mgd

days

days/week

months/year

mgd

mgd

days

days/week

months/year

mgd

mgd

days

days/week

months/year

mgd

mgd

days

days/week

months/year

mgd

mgd

days

days/week

months/year

mgd

mgd

days

SECTION 5. PRODUCTION (40 CFR 122.21(G)(5))
5.1
Do any effluent limitation guidelines (ELGs) promulgated by EPA under Section 304 of the CWA apply to your
facility?

Production-Based Limitations

Applicable ELGs



Yes



No  SKIP to Section 6.

5.2

Provide the following information on applicable ELGs.
ELG Category
ELG Subcategory

5.3

Are any of the applicable ELGs expressed in terms of production (or other measure of operation)?


5.4

EPA Form 3510-2C

Yes



Regulatory Citation

No  SKIP to Section 6.

Provide an actual measure of daily production expressed in terms and units of applicable ELGs.
Outfall
Operation, Product, or Material
Quantity per Day
Number

Unit of
Measure

Page 3

EPA Identification Number

5.5

NPDES Permit Number

Facility Name

OMB No. 2040-0004
Expires MM/DD/YYYY

Are you requesting alternative limits based on an anticipated increase in the actual production during the next permit
term? (Consult with your NPDES permitting authority to determine what information needs to be submitted and
when.)





Yes

No

SECTION 6. IMPROVEMENTS (40 CFR 122.21(G)(6))
6.1
Are you presently required by any federal, state, or local authority to meet an implementation schedule for
constructing, upgrading, or operating wastewater treatment equipment or practices or any other environmental
programs that could affect the discharges described in this application?

Upgrades and Improvements


6.2

6.3



Yes

No  SKIP to Item 6.3.

Briefly identify each applicable project in the table below.
Affected
Brief Identification and Description of
Outfalls
Project
(list outfall
number)

Final Compliance Dates

Source(s) of
Discharge

Required

Projected

Have you attached sheets describing any additional water pollution control programs (or other environmental
projects that may affect your discharges) that you now have underway or planned? (optional item)



Yes





No

Not applicable

Effluent and Intake Characteristics

SECTION 7. EFFLUENT AND INTAKE CHARACTERISTICS (40 CFR 122.21(G)(7))
See the instructions to determine the pollutants and parameters you are required to monitor and, in turn, the tables you must
complete. Not all applicants need to complete each table.
Table A. Conventional and Non-Conventional Pollutants
7.1
Are you requesting a waiver from your NPDES permitting authority for any Table A pollutants for any of your
outfalls?
 Yes
 No  SKIP to Item 7.3.
7.2
If yes, indicate the applicable outfalls below or check the appropriate box to indicate that you are requesting a waiver
for all outfalls. Attach waiver request and other required information to the application.
Outfall number _____

7.3

Outfall number _____




I am requesting a waiver for some pollutants at all outfalls.



Yes

Outfall number _____

I am requesting a waiver for all pollutants at all outfalls  SKIP to Item 7.4.
Have you completed monitoring for all Table A pollutants at each of your outfalls for which a waiver has not been
requested and attached the results to this application package?

Table B. Toxic Metals, Cyanide, Total Phenols, and Organic Toxic Pollutants
7.4
Do any of the facility’s processes that contribute wastewater fall into one or more of the primary industry categories
listed in Exhibit 2C–3? (See end of instructions for exhibit.)


7.5



No  SKIP to Item 7.8.

Have you checked “Testing Required” for all toxic metals, cyanide, and total phenols in Section 1 of Table B?



EPA Form 3510-2C

Yes
Yes

Page 4

EPA Identification Number

7.6

7.7

7.8

7.9

Effluent and Intake Characteristics Continued

7.10

7.11

NPDES Permit Number

Facility Name

OMB No. 2040-0004
Expires MM/DD/YYYY

List the applicable primary industry categories and check the boxes indicating the required GC/MS fraction(s)
identified in Exhibit 2C–3.
Required GC/MS Fraction(s)
Primary Industry Category
(check applicable boxes)
 Volatile

 Acid

 Base/neutral

 Pesticide

 Volatile

 Acid

 Base/neutral

 Pesticide

 Volatile

 Acid

 Base/neutral

 Pesticide

Have you checked “Testing Required” for all required pollutants in Sections 2 through 5 of Table B for each of the
GC/MS fractions checked in Item 7.6?



Yes
Have you checked “Believed Present” or “Believed Absent” for all pollutants listed in Sections 1 through 5 of Table B
where testing is not required?
 Yes
Have you provided (1) quantitative data for those Section 1, Table B, pollutants for which you have indicated testing
is required or (2) quantitative data or other required information for those Section 1, Table B, pollutants that you
have indicated are “Believed Present” in your discharge?
 Yes
Does the applicant qualify for a small business exemption under the criteria specified in the instructions?
Note that you qualify at the top of Table B,
 Yes  then
 No
SKIP to Item 7.12.
Have you provided (1) quantitative data for those Sections 2 through 5, Table B, pollutants for which you have
determined testing is required or (2) quantitative data or an explanation for those Sections 2 through 5, Table B,
pollutants you have indicated are “Believed Present” in your discharge?
 Yes

Table C. Certain Conventional and Non-Conventional Pollutants
7.12 Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed in Table C
for all outfalls?
 Yes
7.13 Have you completed Table C by providing quantitative data for those pollutants that are limited either directly or
indirectly in an ELG? You must provide quantitative data even if the pollutant is “Believed Absent.”
 Yes
 Not applicable
7.14 Have you completed Table C by providing quantitative data or an explanation for those pollutants for which you have
indicated “Believed Present”?
 Yes
Table D. Certain Hazardous Substances and Asbestos
7.15 Have you indicated whether pollutants are “Believed Present” or “Believed Absent” for all pollutants listed in Table D
for all outfalls?
 Yes
7.16 Have you completed Table D by (1) describing the reasons the applicable pollutants are expected to be discharged
and (2) providing quantitative data, if available?
 Yes
 No
Table E. 2,3,7,8-Tetrachlorodibenzo-p-Dioxin (2,3,7,8-TCDD)
7.17 Does the facility use or manufacture one or more of the 2,3,7,8-TCDD congeners listed in the instructions, or do you
know or have reason to believe that TCDD is or may be present in the effluent?


7.18

EPA Form 3510-2C

Yes  Complete Table E.



No  SKIP to Section 8.

Have you completed Table E by reporting qualitative data for TCDD?
 Yes
Page 5

EPA Identification Number

NPDES Permit Number

Facility Name

OMB No. 2040-0004
Expires MM/DD/YYYY

Used or Manufactured
Toxics

SECTION 8. USED OR MANUFACTURED TOXICS (40 CFR 122.21(G)(9))
8.1
Is any pollutant listed in Table B a substance or a component of a substance used or manufactured at your facility as
an intermediate or final product or byproduct?
 Yes
 No  SKIP to Section 9.
8.2
List the pollutants below. Attach additional sheets, if necessary.
1.

4.

7.

2.

5.

8.

3.

6.

9.

Biological Toxicity Tests

SECTION 9. BIOLOGICAL TOXICITY TESTS (40 CFR 122.21(G)(11))
9.1
Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been made
within the last three years on (1) any of your discharges or (2) a receiving water in relation to your discharge?


9.2



Yes

Identify the tests and their purposes below.
Test(s)

Purpose of Test(s)

No  SKIP to Section 10.

Submitted to NPDES
Permitting Authority?



Yes



No



Yes



No



Yes



No

Date Submitted

SECTION 10. CONTRACT ANALYSES (40 CFR 122.21(G)(12))
10.1 Were any of the analyses reported in Section 7 performed by a contract laboratory or consulting firm?



Contract Analyses

10.2

Yes



No  SKIP to Section 11.

Provide information for each contract laboratory or consulting firm below.
Laboratory Number 1
Laboratory Number 2
Name of
laboratory/firm

Laboratory Number 3

Laboratory address

Phone number
Pollutant(s) analyzed

EPA Form 3510-2C

Page 6

EPA Identification Number

NPDES Permit Number

Facility Name

OMB No. 2040-0004
Expires MM/DD/YYYY

Additional Information

SECTION 11. ADDITIONAL INFORMATION (40 CFR 122.21(G)(13))
11.1 Has the NPDES permitting authority requested additional information?


11.2



Yes

No  SKIP to Section 12.

List the information requested and attach it to this application.
1.

4.

2.

5.

3.

6.

Checklist and Certification Statement

SECTION 12. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(A) AND (D))
12.1 In Column 1 below, mark the sections of Form 2C that you have completed and are submitting with your application.
For each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note
that not all applicants are required to complete all sections or provide attachments.
Column 1
Column 2



Section 1: Outfall Location



w/ attachments



Section 2: Line Drawing



w/ line drawing



w/ additional attachments



Section 3: Average Flows and
Treatment



w/ attachments



w/ list of each user of
privately owned treatment
works



Section 4: Intermittent Flows



w/ attachments



Section 5: Production



w/ attachments







w/ request for a waiver and
supporting information
w/ small business exemption
request



w/ other attachments



w/ Table A



w/ Table B



w/ Table C



w/ Table D



w/ Table E



w/ analytical results as an
attachment



w/ attachments



w/ attachments



w/ attachments



w/ attachments



w/ attachments






Section 7: Effluent and Intake
Characteristics



Section 8: Used or Manufactured
Toxics
Section 9: Biological Toxicity
Tests



Section 10: Contract Analyses






EPA Form 3510-2C

Section 6: Improvements

w/ optional additional
sheets describing any
additional pollution control
plans
w/ explanation for
identical outfalls

Section 11: Additional
Information
Section 12: Checklist and
Certification Statement

w/ attachments



Page 7

EPA Identification Number

NPDES Permit Number

Facility Name

OMB No. 2040-0004
Expires MM/DD/YYYY

Checklist and Certification Statement

SECTION 12. CHECKLIST AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d)) (Continued)
12.2 Provide the following certification. (See instructions to determine the appropriate person to sign the application.)

EPA Form 3510-2C

Certification Statement
I certify under penalty of law 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 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 submitted 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 (print or type first and last name)
Official title
Signature

Date signed

Page 8

EPA Identification Number

NPDES Permit Number

Facility Name

OMB No. 2040-0004
Expires MM/DD/YYYY

Outfall Number

TABLE A. CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(iii)) 1
Pollutant

Intake

Effluent

Waiver
Requested

Maximum
Daily
Discharge

Units

(specify)

(if applicable)

(required)

Maximum
Monthly
Discharge
(if available)

Long-Term
Average Daily
Discharge
(if available)

(optional)

Number of
Analyses



Check here if you have applied to your NPDES permitting authority for a waiver for all of the pollutants listed on this table for the noted outfall.

1.

Biochemical oxygen demand
(BOD 5 )



2.

Chemical oxygen demand
(COD)



3.

Total organic carbon (TOC)



4.

Total suspended solids (TSS)

5.

Ammonia (as N)



6.

Flow



Rate

Temperature (winter)



°C

°C

Temperature (summer)



°C

°C

pH (minimum)



Standard units

s.u.

pH (maximum)



Standard units

s.u.

7.

8.
1



Long-Term
Average Value

Number of
Analyses

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or

required under 40 CFR Chapter I, Subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

EPA Form 3510-2C

Page 9

This page intentionally left blank.

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)



OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Check here if you qualify as a small business per the instructions to Form 2C and, therefore, do not need to submit quantitative data for any of the organic toxic pollutants in Sections
2 through 5 of this table. Note, however, that you must still indicate in the appropriate column of this table if you believe any of the pollutants listed are present in your discharge.

Section 1. Toxic Metals, Cyanide, and Total Phenols
1.1

Antimony, total
(7440-36-0)







1.2

Arsenic, total
(7440-38-2)







1.3

Beryllium, total
(7440-41-7)







1.4

Cadmium, total
(7440-43-9)







1.5

Chromium, total
(7440-47-3)







1.6

Copper, total
(7440-50-8)







1.7

Lead, total
(7439-92-1)







1.8

Mercury, total
(7439-97-6)







1.9

Nickel, total
(7440-02-0)







1.10

Selenium, total
(7782-49-2)







1.11

Silver, total
(7440-22-4)







EPA Form 3510-2C

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Page 11

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

Thallium, total
1.12
(7440-28-0)







Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Cyanide, total
1.14



(57-12-5)
Mass
Concentration
1.15 Phenols, total



Mass
Section 2. Organic Toxic Pollutants (GC/MS Fraction—Volatile Compounds)
1.13

Zinc, total
(7440-66-6)







2.1

Acrolein
(107-02-8)







2.2

Acrylonitrile
(107-13-1)







2.3

Benzene
(71-43-2)







2.4

Bromoform
(75-25-2)







2.5

Carbon tetrachloride
(56-23-5)







2.6

Chlorobenzene
(108-90-7)







2.7

Chlorodibromomethane
(124-48-1)







2.8

Chloroethane
(75-00-3)







EPA Form 3510-2C

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Page 12

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

2.9

2-chloroethylvinyl ether
(110-75-8)

2.10 Chloroform (67-66-3)













2.11

Dichlorobromomethane
(75-27-4)







2.12

1,1-dichloroethane
(75-34-3)







2.13

1,2-dichloroethane
(107-06-2)







2.14

1,1-dichloroethylene
(75-35-4)







2.15

1,2-dichloropropane
(78-87-5)







2.16

1,3-dichloropropylene
(542-75-6)







2.17

Ethylbenzene
(100-41-4)







2.18

Methyl bromide
(74-83-9)







2.19

Methyl chloride
(74-87-3)







2.20

Methylene chloride
(75-09-2)







2.21

1,1,2,2- tetrachloroethane
(79-34-5)







EPA Form 3510-2C

Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Page 13

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

Tetrachloroethylene
2.22
(127-18-4)







2.23

Toluene
(108-88-3)







2.24

1,2-trans-dichloroethylene
(156-60-5)







2.25

1,1,1-trichloroethane
(71-55-6)







2.26

1,1,2-trichloroethane
(79-00-5)







2.27

Trichloroethylene
(79-01-6)







2.28

Vinyl chloride
(75-01-4)







Section 3. Organic Toxic Pollutants (GC/MS Fraction—Acid Compounds)
3.1

2-chlorophenol
(95-57-8)







3.2

2,4-dichlorophenol
(120-83-2)







3.3

2,4-dimethylphenol
(105-67-9)







3.4

4,6-dinitro-o-cresol
(534-52-1)







3.5

2,4-dinitrophenol
(51-28-5)







EPA Form 3510-2C

Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Page 14

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

3.6

2-nitrophenol
(88-75-5)







3.7

4-nitrophenol
(100-02-7)







3.8

p-chloro-m-cresol
(59-50-7)







3.9

Pentachlorophenol
(87-86-5)







Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Mass
Concentration
Mass

Concentration
Mass
Concentration
2,4,6-trichlorophenol
3.11



(88-05-2)
Mass
Section 4. Organic Toxic Pollutants (GC/MS Fraction—Base /Neutral Compounds)
Concentration
Acenaphthene
4.1



(83-32-9)
Mass
Concentration
Acenaphthylene
4.2



(208-96-8)
Mass
3.10

Phenol
(108-95-2)







4.3

Anthracene
(120-12-7)







4.4

Benzidine
(92-87-5)







4.5

Benzo (a) anthracene
(56-55-3)







4.6

Benzo (a) pyrene
(50-32-8)







EPA Form 3510-2C

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Page 15

EPA Identification Number

Facility Name

NPDES Permit Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

4.7

3,4-benzofluoranthene
(205-99-2)







4.8

Benzo (ghi) perylene
(191-24-2)







4.9

Benzo (k) fluoranthene
(207-08-9)







4.10

Bis (2-chloroethoxy) methane
(111-91-1)







4.11

Bis (2-chloroethyl) ether
(111-44-4)







4.12

Bis (2-chloroisopropyl) ether
(102-80-1)







4.13

Bis (2-ethylhexyl) phthalate
(117-81-7)







4.14

4-bromophenyl phenyl ether
(101-55-3)







4.15

Butyl benzyl phthalate
(85-68-7)







4.16

2-chloronaphthalene
(91-58-7)







4.17

4-chlorophenyl phenyl ether
(7005-72-3)







4.18

Chrysene
(218-01-9)







4.19

Dibenzo (a,h) anthracene
(53-70-3)







EPA Form 3510-2C

Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Page 16

EPA Identification Number

Facility Name

NPDES Permit Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

1,2-dichlorobenzene
4.20
(95-50-1)







4.21

1,3-dichlorobenzene
(541-73-1)







4.22

1,4-dichlorobenzene
(106-46-7)







4.23

3,3-dichlorobenzidine
(91-94-1)







4.24

Diethyl phthalate
(84-66-2)







4.25

Dimethyl phthalate
(131-11-3)







4.26

Di-n-butyl phthalate
(84-74-2)







4.27

2,4-dinitrotoluene
(121-14-2)







4.28

2,6-dinitrotoluene
(606-20-2)







4.29

Di-n-octyl phthalate
(117-84-0)







4.30

1,2-Diphenylhydrazine
(as azobenzene) (122-66-7)







4.31

Fluoranthene
(206-44-0)







4.32

Fluorene
(86-73-7)







EPA Form 3510-2C

Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Page 17

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Units

Believed
Absent

(specify)

Maximum
Daily
Discharge
(required)

Hexachlorobenzene
4.33
(118-74-1)







4.34

Hexachlorobutadiene
(87-68-3)







4.35

Hexachlorocyclopentadiene
(77-47-4)







4.36

Hexachloroethane
(67-72-1)







4.37

Indeno (1,2,3-cd) pyrene
(193-39-5)







4.38

Isophorone
(78-59-1)







4.39

Naphthalene
(91-20-3)







4.40

Nitrobenzene
(98-95-3)







4.41

N-nitrosodimethylamine
(62-75-9)







4.42

N-nitrosodi-n-propylamine
(621-64-7)







4.43

N-nitrosodiphenylamine
(86-30-6)







4.44

Phenanthrene
(85-01-8)







4.45

Pyrene
(129-00-0)







EPA Form 3510-2C

Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Page 18

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

1,2,4-trichlorobenzene
4.46



(120-82-1)
Section 5. Organic Toxic Pollutants (GC/MS Fraction—Pesticides)
5.1

Aldrin
(309-00-2)







5.2

α-BHC
(319-84-6)







5.3

β-BHC
(319-85-7)







5.4

γ-BHC
(58-89-9)







5.5

δ-BHC
(319-86-8)







5.6

Chlordane
(57-74-9)







5.7

4,4’-DDT
(50-29-3)







5.8

4,4’-DDE
(72-55-9)







5.9

4,4’-DDD
(72-54-8)







5.10

Dieldrin
(60-57-1)







5.11

α-endosulfan
(115-29-7)







EPA Form 3510-2C

Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Page 19

EPA Identification Number

Facility Name

NPDES Permit Number

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

β-endosulfan
5.12
(115-29-7)







5.13

Endosulfan sulfate
(1031-07-8)







5.14

Endrin
(72-20-8)







5.15

Endrin aldehyde
(7421-93-4)







5.16

Heptachlor
(76-44-8)







Heptachlor epoxide
5.17 (1024-57-3)







PCB-1242
5.18 (53469-21-9)







PCB-1254
5.19 (11097-69-1)







PCB-1221
5.20 (11104-28-2)







PCB-1232
5.21 (11141-16-5)







PCB-1248
5.22 (12672-29-6)







PCB-1260
5.23 (11096-82-5)







PCB-1016
5.24 (12674-11-2)







EPA Form 3510-2C

Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Page 20

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE B. TOXIC METALS, CYANIDE, TOTAL PHENOLS, AND ORGANIC TOXIC POLLUTANTS (40 CFR 122.21(g)(7)(v))1
Presence or Absence
(check one)

Pollutant/Parameter

(and CAS Number, if available)

Testing
Required

Believed
Present

Believed
Absent

Units

(specify)

Maximum
Daily
Discharge
(required)

Toxaphene
5.25 (8001-35-2)







Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

Long-Term
Average
Daily
Discharge
(if available)

(optional)

Number
of
Analyses

LongNumber
Term
of
Average
Analyses
Value

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR Chapter I, Subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

1

EPA Form 3510-2C

Page 21

This page intentionally left blank.

NPDES Permit Number

EPA Identification Number

Facility Name

Outfall Number

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1
Presence or Absence
(check one)

Pollutant

Believed
Present

Units

Believed
Absent

(specify)

Maximum Daily
Discharge
(required)

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

(optional)

Long-Term
Average Daily
Discharge
(if available)

Number of
Analyses

Long-Term
Average
Value

Number of
Analyses



Check here if you believe all pollutants in Table C to be present in your discharge from the noted outfall. You need not complete the “Presence or Absence” column of Table C for
each pollutant.



Check here if you believe all pollutants in Table C to be absent in your discharge from the noted outfall. You need not complete the “Presence or Absence” column of Table C for
each pollutant.

1.

Bromide





2.

Chlorine, total
residual





3.

Color





4.

Fecal coliform





(16984-48-8)

Fluoride





6

Nitrate-nitrite





7.

Nitrogen, total
organic (as N)





8.

Oil and grease





9.

Phosphorus (as
P), total (7723-14-0)





10. Sulfate (as SO 4 )





11. Sulfide (as S)





5.

(24959-67-9)

(14808-79-8)

EPA Form 3510-2C

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Page 23

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1
Presence or Absence
(check one)

Pollutant

Believed
Present

12. Sulfite (as SO 3 )





13. Surfactants





Aluminum, total
14. (7429-90-5)





15. Barium, total





16. Boron, total





Cobalt, total
17. (7440-48-4)





18. Iron, total





19. Magnesium, total
(7439-95-4)





Molybdenum,
20. total





total
21. Manganese,
(7439-96-5)





22. Tin, total

(7440-31-5)





23. Titanium, total





(14265-45-3)

(7440-39-3)
(7440-42-8)

(7439-89-6)

(7439-98-7)

(7440-32-6)

EPA Form 3510-2C

Units

Believed
Absent

(specify)

Maximum Daily
Discharge
(required)

Concentration
Mass
Concentration
Mass

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

(optional)

Long-Term
Average Daily
Discharge
(if available)

Number of
Analyses

Long-Term
Average
Value

Number of
Analyses

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Page 24

NPDES Permit Number

EPA Identification Number

Facility Name

Outfall Number

TABLE C. CERTAIN CONVENTIONAL AND NON-CONVENTIONAL POLLUTANTS (40 CFR 122.21(g)(7)(vi))1
Presence or Absence
(check one)

Pollutant

Believed
Present

Believed
Absent

Units

(specify)

(required)

24. Radioactivity
Alpha, total





Beta, total





Radium, total





Radium 226, total





Maximum Daily
Discharge

OMB No. 2040-0004
Expires MM/DD/YYYY

Intake

Effluent

Maximum
Monthly
Discharge
(if available)

(optional)

Long-Term
Average Daily
Discharge
(if available)

Number of
Analyses

Long-Term
Average
Value

Number of
Analyses

Concentration
Mass
Concentration
Mass
Concentration
Mass
Concentration
Mass

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR Chapter I, Subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

1

EPA Form 3510-2C

Page 25

This page intentionally left blank.

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1
Presence or Absence
(check one)
Pollutant
Reason Pollutant Believed Present in Discharge
Believed
Believed
Present
Absent
1.

Asbestos





2.

Acetaldehyde





3.

Allyl alcohol





4.

Allyl chloride





5.

Amyl acetate





6.

Aniline





7.

Benzonitrile





8.

Benzyl chloride





9.

Butyl acetate





10. Butylamine





11. Captan





12. Carbaryl





13. Carbofuran





14. Carbon disulfide





15. Chlorpyrifos





16. Coumaphos





17. Cresol





18. Crotonaldehyde





19. Cyclohexane





EPA Form 3510-2C

OMB No. 2040-0004
Expires MM/DD/YYYY

Available Quantitative Data
(specify units)

Page 27

EPA Identification Number

Facility Name

NPDES Permit Number

Outfall Number

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1
Presence or Absence
(check one)
Pollutant
Reason Pollutant Believed Present in Discharge
Believed
Believed
Present
Absent
20. 2,4-D (2,4-dichlorophenoxyacetic acid)





21. Diazinon





22. Dicamba





23. Dichlobenil





24. Dichlone





25. 2,2-dichloropropionic acid





26. Dichlorvos





27. Diethyl amine





28. Dimethyl amine





29. Dintrobenzene





30. Diquat





31. Disulfoton





32. Diuron





33. Epichlorohydrin





34. Ethion





35. Ethylene diamine





36. Ethylene dibromide





37. Formaldehyde





38. Furfural





EPA Form 3510-2C

OMB No. 2040-0004
Expires MM/DD/YYYY

Available Quantitative Data
(specify units)

Page 28

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1
Presence or Absence
(check one)
Pollutant
Reason Pollutant Believed Present in Discharge
Believed
Believed
Present
Absent
39. Guthion





40. Isoprene





41. Isopropanolamine





42. Kelthane





43. Kepone





44. Malathion





45. Mercaptodimethur





46. Methoxychlor





47. Methyl mercaptan





48. Methyl methacrylate





49. Methyl parathion





50. Mevinphos





51. Mexacarbate





52. Monoethyl amine





53. Monomethyl amine





54. Naled





55. Naphthenic acid





56. Nitrotoluene





57. Parathion





EPA Form 3510-2C

OMB No. 2040-0004
Expires MM/DD/YYYY

Available Quantitative Data
(specify units)

Page 29

EPA Identification Number

NPDES Permit Number

Facility Name

Outfall Number

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1
Presence or Absence
(check one)
Pollutant
Reason Pollutant Believed Present in Discharge
Believed
Believed
Present
Absent
58. Phenolsulfonate





59. Phosgene





60. Propargite





61. Propylene oxide





62. Pyrethrins





63. Quinoline





64. Resorcinol





65. Strontium





66. Strychnine





67. Styrene

















71. Trichlorofon





72. Triethanolamine





73. Triethylamine





74. Trimethylamine





75. Uranium





76. Vanadium





68.

2,4,5-T (2,4,5-trichlorophenoxyacetic
acid)

69. TDE (tetrachlorodiphenyl ethane)
70.

2,4,5-TP [2-(2,4,5-trichlorophenoxy)
propanoic acid]

EPA Form 3510-2C

OMB No. 2040-0004
Expires MM/DD/YYYY

Available Quantitative Data
(specify units)

Page 30

EPA Identification Number

Facility Name

NPDES Permit Number

Outfall Number

TABLE D. CERTAIN HAZARDOUS SUBSTANCES AND ASBESTOS (40 CFR 122.21(g)(7)(vii))1
Presence or Absence
(check one)
Pollutant
Reason Pollutant Believed Present in Discharge
Believed
Believed
Present
Absent
77. Vinyl acetate





78. Xylene





79. Xylenol





80. Zirconium





OMB No. 2040-0004
Expires MM/DD/YYYY

Available Quantitative Data
(specify units)

Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR Chapter I, Subchapter N or O. See instructions and 40 CFR 122.21(e)(3).

1

EPA Form 3510-2C

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EPA Identification Number

NPDES Permit Number

Facility Name

TABLE E. 2,3,7,8-TETRACHLORODIBENZO-P-DIOXIN (2,3,7,8-TCDD) (40 CFR 122.21(g)(7)(viii))
Presence or
TCDD
Absence
Congeners
(check one)
Pollutant
Used or
Believed Believed
Manufactured Present
Absent
2,3,7,8-TCDD





Outfall Number

OMB No. 2040-0004
Expires MM/DD/YYYY

Results of Screening Procedure



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EPA Form 3510-2C

Page 33