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l 1. Site-specific conditions: <br />a) Does [his facility have bulk srorage of diesel fuel, gasoline, solvents, fertilizer, <br />or oNer hazardous materials on site'? ^ No ®Yes <br />b) Is this operation located within one mile of a landfill, or any mine or mill tailings? ®No ^Yes <br />c) Does d:r Jewa[ering area have or possibly have groundwater contamination, such u <br />Plumes rrom leaking underground storage tanks, etc.? ®No ^ Yes <br />[f YES roe any of these, please show location of the landfill, tailings or possible groundwarer contamination on [he location map in item 8 or in <br />the general sketch in item l0. Alease explain the location, extent of contamination, and possible effect on the discharges from this facility. <br />l2. Chemical vestment: Will any tlocculants tsettline agents or chemical additives) be used to treat water prior [o discharge? <br />®No f_' Yes if YES, list here, and include the Material Safety Data Sheet tMSDS): <br />Chemical Name' I Manufacturer Purpose In Which Waste Stream? <br />I <br />I <br />' If the chemical formula is unknown or contidential, provide the manufacturer's name, contact person, address and phone number or a copy <br />of me ;nanufacturer's brochure, product label information or materials handling data sheet for each product used. Please list the major <br />constituents or active ingredient(s), if known. <br />13. Are the receiving waters, indicated in item ~. a ditch or storm sewer? <br />® No ^ Yes <br />If YES, submit documentation that the owner of the ditch or storm sewer allows this discharge. No certification will be processed unless <br />documentation of approval is received. <br />Note: A discharge permit does not allow a discharge into a ditch or municipal storm sewer system without. Ute approval of the ownerlopera[or of <br />drat system. Please provide documentation of approval from the ditch company or owner of the storm sewer for all new discharges. <br />14. Flow measurement: What method of flow measurement will be used for each discharge point (e.g., v-notch weir, pump capacity, parshall <br />flume, etc.)? Ptunp Capacity <br />