NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) APPLICATION FOR INDIVIDUAL PERMIT TO DISCHARGE INDUSTRIAL WASTEWATER

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1 3800-PM-BCW0008b Rev. 8/2017 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF CLEAN WATER NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) APPLICATION FOR INDIVIDUAL PERMIT TO DISCHARGE INDUSTRIAL WASTEWATER Before completing this form, please read the instructions (3800-PM-BCW0008a). INSTRUCTIONS MAY RESULT IN DENIAL OF THE APPLICATION. Related ID#s (If Known) Client ID# APS ID# Date Received: Site ID# Facility ID# Permit : Applicant/Operator Name New Permit (Anticipated Discharge Date: ) Permit Renewal: NPDES PA Permit Expiration Date: Permit Renewal Application Due Date: WQM Permit No(s).: WQM Permit Issuance Date(s): Currently Using edmr System? Yes No Start Date: Is there on-site sewage treatment facility? Yes No GENERAL INFORMATION Auth ID: FAILURE TO FOLLOW THE DEP USE ONLY PDG? 25 Pa. Code 92a.26 Fee Category (See instructions for fees) Minor facility without ELG Minor facility with ELG Major facility < 250 MGD Major facility 250 MGD CAAP IW Stormwater Is applicant a small business? If Yes, is the facility operated by operator(s) certified in compliance with the Operators Certification Act? Yes No Describe the nature of the business or operations resulting in discharge(s): Yes No SIC Code Primary? Description NAICS Code Primary? Description OTHER ENVIRONMENTAL PERMITS Type of Permit Agency That Issued Permit Date Issued DISCHARGE INFORMATION 1. Attach a site plan, a line drawing with a water balance, and topographic map(s) that present the information requested in the instructions. Attached : Yes No 2. Total Hardness Upstream of Process Wastewater Outfall (mg/l): Basis: - 1 -

2 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: 3. List all discharge points (outfalls) and internal monitoring points (IMPs). If numbers were previously assigned in a permit, use those numbers. Order sequentially and use additional pages as necessary. LATITUDE LONGITUDE RECEIVING WATERS Outfall / IMP Deg Min Sec Deg Min Sec Name of Receiving Waters Ch. 93 Class. Impaired? TMDL? - 2 -

3 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: 4. List all outfalls and IMPs in the same order as in question 2, above, and provide the requested information. Attach additional pages as necessary. See instructions. Outfall / IMP DISCHARGE CHARACTERIZATION Process Non-Process Stormwater Sewage Groundwater AAPF Combined Design Flow (MGD) Average Flow During Production / Operation (MGD) Maximum Flow During Production / Operation (MGD) - 3 -

4 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: 5. List all outfalls and IMPs in the same order as in questions 2 and 3, above, and provide the requested information. Attach additional pages as necessary. See instructions. Outfall / IMP Wastewater or Stormwater Description Discharge Type Frequency Batch Discharges Hours / Day Days / Week Discharge Cycles/Day Length of Discharge Cycle (Hrs) Batch Discharge Rate (MGD) - 4 -

5 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: TREATMENT FACILITY INFORMATION Complete this sheet for each existing and proposed industrial waste, sewage and/or stormwater treatment facility (one sheet per facility). Treatment Facility Name: Effluent Discharged To Outfall / IMP : 1. Provide a narrative description of the wastewater treatment process. Attach a line drawing or process flow diagram to the application. 2. List each treatment unit at the facility in sequential order of treatment. Treatment Unit Description Method for Handling and Disposal of Solid or Liquid Residue Resulting from Treatment 3. Describe any proposed upgrades to this treatment facility within the next five years. 4. Identify all chemicals that have been used for wastewater treatment over the past two years. Chemical Name Purpose Max Usage Rate Units Acrylamide? 5. List any additional proposed wastewater treatment chemicals anticipated in the next five years. Chemical Name Purpose Max Usage Rate Units Acrylamide? - 5 -

6 Chemical Additive Name Outfall / IMP Purpose Usage Frequency Max Usage Rate Units 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: CHEMICAL ADDITIVES 1. Identify all chemical additives that have been introduced to any waste stream over the past two years. 2. List all chemical additives that the applicant is requesting approval to use upon issuance of the permit by DEP. Identify the point of introduction on a line or process diagram. Chemical Additive Name Outfall / IMP Purpose Proposed Usage Frequency Proposed Max Usage Rate Units 3. List all chemical additives in the same order as question 2, above, and provide the requested information. For chemical additives that are not on DEP s Approved List, submit New Chemical Additive Request Form(s) to DEP s Central Office. For chemical additives that are on DEP s Approved List but a Chemical Additives Notification Form was not previously submitted, attach a Chemical Additives Notification Form to the application. Chemical Additive Name On Approved List? Notification Form Attached? Notification Form Previously Submitted? Notification Form Submission Date Analytical Method - 6 -

7 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: PRODUCTION DATA FOR EFFLUENT LIMITATION GUIDELINES (ELGs) Complete this section for each production line with an applicable ELG. See instructions and use additional sheets as necessary. 1. Production line and process description: 2. Applicable ELG: 40 CFR: Subpart: 3. Is this production considered a new source? Yes No 4. Outfall / IMP receiving wastewater: 5. Units of production measurement for ELG: 6. Design production capacity: 7. Complete the table below for the five last years of production. Report production data using the same units of measurement as reported in question 4. Parameter Total Annual Production Max Monthly Production Month of Max Production Avg Annual Production Avg Production Hours/Day Avg Production Days/Month Avg Annual Water Usage (MGD) Avg Annual Wastewater Flow (MGD) Production Years Average annual production over the past five years: Units: 9. Anticipated average annual production for the next five years: Units: 10. Explain the basis for the anticipated average annual production for the next five years: 11. Attach any pertinent information from the applicable ELG in 40 CFR that would allow DEP to appropriately determine technology-based effluent limitations

8 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: ANTI-DEGRADATION If the applicant is proposing a new or increased discharge to High Quality (HQ) or Exceptional (EV) waters, Module 4 (Anti Degradation Module) must be attached to the application. In addition, for HQ waters only, if the analysis concludes that the new or increased discharge will produce a measurable change in water quality, a social or economic justification (SEJ) must be attached if the applicant desires approval for the discharge. 1. Is the Anti-Degradation Module (Module 4) attached to the application? Yes No 2. Is a social or economic justification (SEJ) (HQ waters only) attached to the application? Yes No VARIANCES If the applicant is requesting a variance authorized under federal regulations at 40 CFR (m), complete the section below and attach to this application documentation necessary under federal regulations to support the variance request. 1. Description of variance requested: 2. Federal regulation authorizing the variance: 3. Supporting documentation attached to the application? Yes No LABORATORY INFORMATION Did an off-site laboratory perform any of the analyses required by this application? Yes No If Yes, provide the information below. Name Analyses Performed: Address Phone ( ) Name Analyses Performed: Address Phone ( ) COMPLIANCE HISTORY REVIEW Is the facility owner or operator in violation of any DEP regulation, permit, order or schedule of compliance at this or any other facility? Yes No If Yes, list each permit, order or schedule of compliance and provide compliance status. Use additional sheets as necessary. Permit Program: Permit Program: Permit Program: Permit : Permit : Permit : Brief Description of Non-Compliance: Steps Taken to Achieve Compliance Date(s) Compliance Achieved Current Compliance Status: In Compliance In Non-Compliance - 8 -

9 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: 1. Summary of Required Analyses (see instructions): Outfall / IMP POLLUTANT IDENTIFICATION AND ANALYSIS Pollutant Groups which must be sampled for and analyzed Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7 Other Pollutants Analyzed 2. Is screening for 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) required? Yes No Method used: Describe results: 3. Other Potentially Toxic Pollutants Known or Expected to be Present in the Discharge. a. GC/MS "Five Peaks" Pollutants (see instructions). Outfall / IMP Group Number (3-6) Chemical or Compound Name b. Other Potential Pollutants. Outfall / IMP Chemical Substance or Compound Name Quantitation Limit Avg Effluent Concentration Reason/Suspected Reason for Presence in Discharge Max Effluent Concentration Avg Concentration Samples Positive / Analyzed Indicate if Presence is Known (K) or Suspected (S) / / / / / If additional peaks were not available for one or more groups with the method used check here and attach an explanation of why the method was selected. 4. Additional Analysis Results Tables may be attached to provide any of the optional site-specific information discussed in Appendix A of the instructions. Optional site-specific data is attached to this application? Yes No - 9 -

10 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: WHOLE EFFLUENT TOXICITY 1. Summarize the results of all Whole Effluent Toxicity (WET) tests completed in the last five years (or attach a separate sheet with these results). If required by the NPDES permit, attach a copy of DEP s WET Analysis Spreadsheet to the application (electronic transmission to DEP is acceptable) that provides replicate data for all species tested and for the most recent four consecutive tests. Outfall Tested: Type of tests completed: Chronic Acute Dilution series used: %, %, %, %, and % effluent Target Instream Waste Concentration (TIWC): % effluent Ceriodaphnia Results (% Effluent) Pimephales Results (% Effluent) Test Date Survival NOEC Reproduction NOEC LC50 Survival NOEC Growth NOEC LC50 Pass or Fail 2. Describe the status of any Phase I or II Toxicity Reduction Evaluation (if applicable): PREPAREDNESS, PREVENTION AND CONTINGENCY (PPC) PLAN The applicant may optionally attach its PPC Plan or related plan to the application. This information may be useful to DEP in completing its review of the application. If the PPC Plan is not attached to the application, DEP may request submission of the Plan during the review. Electronic transmission of large PPC Plans is encouraged. Type or Description of Plan (e.g., PPC, SPCC, etc.) Attached? Date of Latest Plan Update

11 3800-PM-BPNPSM0008b Rev. 8/2017 Applicant Name: COOLING WATER INTAKE STRUCTURES 1. Does the facility use cooling water? Yes No If no, the rest of this section may remain blank 2. Identify the source(s) of cooling water: Surface water Groundwater Treated effluent Treated public water supply Untreated public water supply Independent supplier: Other: 3. Facility Type: New Facility New Offshore O&G Facility Existing Facility Facility below 2 MGD or 25% cooling 4. Is Module 5 is attached to this application? Yes No 5. Number of CWISs at facility: 6. CWIS Flow Data: CWIS ID DIF (MGD) AIF (MGD) Max Screen Velocity (fps) % Used for Cooling % Mean Annual Flow 7. Type of CWIS Location: CWIS ID Type (check box): Canal Canal Canal 8. Impingement Control Technology: CWIS ID Technology (check box): No Controls No Controls No Controls 9. Entrainment Control Technology: CWIS ID Technology (check box): No Controls No Controls No Controls Embayment, Bank or Cove Embayment, Bank or Cove Embayment, Bank or Cove Modified Traveling Screens Modified Traveling Screens Modified Traveling Screens Traveling Screens w/fine Mesh Traveling Screens w/fine Mesh Traveling Screens w/fine Mesh Submerged Offshore Submerged Offshore Submerged Offshore Passive Passive Passive Far Offshore Far Offshore Far Offshore Barrier Net Barrier Net Barrier Net Passive Screens w/fine Mesh Passive Screens w/fine Mesh Passive Screens w/fine Mesh Near-shore Submerged Near-shore Submerged Near-shore Submerged Fish Diversion or Avoidance Fish Diversion or Avoidance Fish Diversion or Avoidance Closed-Cycle Recirculating System Closed-Cycle Recirculating System Closed-Cycle Recirculating System Shoreline Submerged Shoreline Submerged Shoreline Submerged Other Technology Other Technology Other Technology Other Technology Other Technology Other Technology

12 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 1 Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 1 PARAMETERS Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used BOD5 (mg/l) COD (mg/l) TOC (mg/l) TSS (mg/l) Ammonia-Nitrogen (mg/l) Temperature (Winter) ( F) XXX XXX XXX XXX XXX Temperature (Summer) ( F) XXX XXX XXX XXX XXX ph Minimum (S.U.) XXX XXX XXX XXX XXX XXX ph Maximum (S.U.) XXX XXX XXX XXX XXX XXX Fecal Coliform (/100 ml) XXX XXX XXX XXX Oil and Grease (mg/l) TRC (mg/l) XXX XXX XXX Total Phosphorus (mg/l) TKN (mg/l) Nitrite + Nitrate-Nitrogen (mg/l) Total Dissolved Solids (mg/l) Color (Pt-Co Units) XXX XXX XXX Bromide (mg/l) Chloride (mg/l) Sulfate (mg/l) Sulfide (mg/l) Surfactants (mg/l) Fluoride (mg/l) Total Hardness (mg/l)

13 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 2 Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 2 PARAMETERS Aluminum, Total Antimony, Total Arsenic, Total Barium, Total Beryllium, Total Boron, Total Cadmium, Total Chromium, Total Chromium, Hexavalent Cobalt, Total Copper, Total Cyanide, Total Iron, Total Iron, Dissolved Lead, Total Manganese, Total Mercury, Total Molybdenum, Total Nickel, Total Phenols, Total Selenium, Total Silver, Total Thallium, Total Zinc, Total Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

14 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 3 (PAGE 1 OF 2) Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 3 PARAMETERS Acrolein Acrylonitrile Benzene Bromoform Carbon Tetrachloride Chlorobenzene Chlorodibromomethane Chloroethane 2-Chloroethylvinyl Ether Chloroform Dichlorobromomethane 1,1-Dichloroethane 1,2-Dichloroethane 1,1-Dichloroethylene 1,2 Dichloropropane 1,3-Dichloropropylene 1,4-Dioxane Ethylbenzene Methyl Bromide Methyl Chloride Methylene Chloride 1,1,2,2-Tetrachloroethane Tetrachloroethylene Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

15 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 3 (PAGE 2 OF 2) Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 3 PARAMETERS Toluene 1,2-Trans-Dichloroethylene 1,1,1-Trichloroethane 1,1,2-Trichloroethane Trichloroethylene Vinyl Chloride Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

16 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 4 Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 4 PARAMETERS 2-Chlorophenol 2,4-Dichlorophenol 2,4-Dimethylphenol 4,6-Dinitro-o-Cresol 2,4-Dinitrophenol 2-Nitrophenol 4-Nitrophenol P-Chloro-m-Cresol Pentachlorophenol Phenol 2,4,6-Trichlorophenol Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

17 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 5 (PAGE 1 OF 3) Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 5 PARAMETERS Acenaphthene Acenaphthylene Acrylamide Anthracene Benzidine Benzo(a)Anthracene Benzo(a)Pyrene 3,4-Benzo-fluoranthene Benzo(ghi)Perylene Benzo(k)Fluoranthene Bis(2-Chloro-ethoxy)Methane Bis(2-Chloroethyl)Ether Bis(2-Chloro-isopropyl)Ether Bis(2-Ethylhexyl)Phthalate 4-Bromophenyl Phenyl Ether Butyl Benzyl Phthalate 2-Chloronaphthalene 4-Chlorophenyl Phenyl Ether Chrysene Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

18 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 5 (PAGE 2 OF 3) Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 5 PARAMETERS Dibenzo(a,h)Anthracene 1,2-Dichlorobenzene 1,3- Dichlorobenzene 1,4- Dichlorobenzene 3,3 -Dichlorobenzidine Diethyl Phthalate Dimethyl Phthalate Di-n-Butyl Phthalate 2,4-Dinitrotoluene 2,6-Dinitrotoluene Di-n-Octyl Phthalate 1,2-Diphenylhydrazine (as Azobenzene) Fluoranthene Fluorene Hexachlorobenzene Hexechlorobutadiene Hexachlorocyclopentadiene Hexachloroethane Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

19 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 5 (PAGE 3 OF 3) Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 5 PARAMETERS Indeno(1,2,3-cd)Pyrene Isophorone Naphthalene Nitrobenzene N-Nitroso-di-methylamine N-Nitroso-di-n-propylamine N-Nitroso-di-n-phenylamine Phenanthrene Pyrene 1,2,4-Trichlorobenzene Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

20 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 6 (PAGE 1 OF 2) Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 6 PARAMETERS Aldrin Alpha BHC Beta BHC Gamma BHC Delta BHC Chlordane 4,4 -DDT 4,4 -DDE 4,4 -DDD Dieldrin Alpha- Endosulfan Beta-Endosulfan Endosulfan Sulfate Endrin Endrin Aldehyde Heptachlor Heptachlor Epoxide PCB PCB Min/Max Daily Max Avg Monthly Long-Term Avg Conc (lbs/day) Analyses Non- Detect Results QL Used Method Used

21 3800-PM-BCW0008b Rev. 8/2017 APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 6 (PAGE 2 OF 2) Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 6 PARAMETERS PCB-1221 PCB-1232 PCB-1248 PCB-1260 PCB-1016 Toxaphene Min/Max Daily Conc Max Avg Monthly Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

22 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: APPLICANT NAME ANALYSIS RESULTS TABLE POLLUTANT GROUP 7 Please read instructions carefully before completing this form. Outfall / IMP Number (Show location of sampling point on Line Drawing) Treatment Facility Influent Sampling Results (Show location of sampling point on Line Drawing) Sampling Results (Specify Source: ) Background (Upstream) Sampling Results (Specify Location: ) New Discharge (Basis for Information: ) CONCENTRATION / MASS PRESENT POLLUTANT GROUP 7 PARAMETERS Min/Max Daily Max Avg Monthly Conc Gross Alpha (pci/l) XXX XXX Beta, Total (pci/l) XXX XXX Radium 226/228, Total (pci/l) Strontium, Total Uranium, Total Osmotic Pressure (mosm/kg) XXX XXX Additional Parameters Long-Term Avg (lbs/day) Analyses Non- Detect Results QL Used Method Used

23 of Analyses Is the applicant requesting a hazardous substance spill reporting requirement exemption for any of the substances listed in Attachment A, Table 3 of the instructions? Quantitation Limit 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: OTHER TOXIC POLLUANTS AND HAZARDOUS SUBSTANCES TABLE Other Pollutants Which Must Be Identified If Known Or Expected To Be Present in Discharges Please read instructions carefully before completing this form Outfall Chemical Substance or Compound Reason for Presence in Discharge Avg Effluent Concentration Max Effluent Concentration Yes No (If Yes, attach the information specified in the instructions)

24 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: CERTIFICATION AND SIGNATURE OF APPLICANT I certify under penalty of law that this document and all attachments and modules were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. See 18 Pa. C.S (relating to unsworn falsification). Name (Type or Print Legibly) Official Title Signature Date (Use corporate or professional seal as appropriate.)

25 3800-PM-BCW0008b Rev. 8/2017 Applicant Name: DOCUMENT REVISION HISTORY Date August 2017 November 2016 May 2016 Revision Reason Corrected units for Osmotic Pressure Updated topographic map requirements; added requirement to report upstream hardness; changed sampling requirements for TCDD; Expanded 316(b) section to include information requirements for facilities below 2MGD or 25% water used for cooling. Moved 1,4-Dioxane from Pollutant Group 5 Results Analysis Table to Group