SECTION III: Facility OWNER MAILING ADDRESS (if different from Authorized Representative) Facility Owner Name Title Parent Company Owner Mailing Address (i.e. PO Box, Street, or Route) City, State, Zip Code Owner Phone No. Alternative Phone No. Contact Fax No. Contact Email Address SECTION IV: DISCHARGE CHARACTERIZATION Average Average Discharge Daily Flow Discharge Daily Flow Type of Wastewater Frequency (gallons of Type of Wastewater Frequency (gallons of (check all that apply): (e.g. Annual, water (check all that apply): (e.g. Annual, water Monthly, Daily) discharged Monthly, Daily) discharged per day) per day) Cleaning or Treated wastewater decontamination from groundwater wastewaters from the remediation project cleaning of treatment equipment for a remediation project Infiltration or injection Other (describe type) of a substance or remedial material for remediation of soil or groundwater Treated wastewater Other (describe type) from dewatering of construction trenches or pits Landspreading or Other (describe type) spray irrigation of agricultural chemical contaminated wastewater ELIGIBILITY CHECKLIST SECTION V: 1. Is the wastewater discharged from and/or to properties within tribal lands (i.e. land owned by or held in trust for the tribes and land within recognized reservation boundaries)? Yes. Your discharge is not eligible for this General Permit. If all discharges from your facility go to or come from properties in tribal lands, you do not require regulation under a WPDES discharge permit. Therefore, skip the rest of the NOI and sign the last page. We will remove you from our tracking system. The Tribe or United States
SECTION III: Facility OWNER MAILING ADDRESS (if different from Authorized Representative) Facility Owner Name Title Parent Company Owner Mailing Address (i.e. PO Box, Street, or Route) City, State, Zip Code Owner Phone No. Alternative Phone No. Contact Fax No. Contact Email Address SECTION IV: DISCHARGE CHARACTERIZATION Type of Wastewater (check all that apply): Discharge Frequency (e.g. Annual, Monthly, Daily) Average Daily Flow (gallons of water discharged per day) Type of Wastewater (check all that apply): Discharge Frequency (e.g. Annual, Monthly, Daily) Average Daily Flow (gallons of water discharged per day) Treated wastewater from groundwater remediation project Cleaning or decontamination wastewaters from the cleaning of treatment equipment for a remediation project Infiltration or injection of a substance or remedial material for remediation of soil or groundwater Other (describe type) Treated wastewater from dewatering of construction trenches or pits Other (describe type) Landspreading or spray irrigation of agricultural chemical contaminated wastewater Other (describe type) SECTION V: ELIGIBILITY CHECKLIST 1. Is the wastewater discharged from and/or to properties within tribal lands (i.e. land owned by or held in trust for the tribes and land within recognized reservation boundaries)? Yes. Your discharge is not eligible for this General Permit. If all discharges from your facility go to or come from properties in tribal lands, you do not require regulation under a WPDES discharge permit. Therefore, skip the rest of the NOI and sign the last page. We will remove you from our tracking system. The Tribe or United States
46566NOI.docx