NPDES Permit No. AR00

All Publicly Owned Treatment Works’ (POTWs) Municipal NPDES permits boilerplate Reporting Requirements state:

The permittee shall provide adequate notice of the following:

Any new introduction of pollutants into the treatment works from an indirect discharger which would be subject to Sections 301 and 306 of the Act if it were directly discharging those pollutants; and

Any substantial change in the volume or character of pollutants being introduced into the treatment works by a source introducing pollutants into the treatment works at the time of issuance of the permit.

Adequate notice shall include information on (i) the quality and quantity of effluent to be introduced into the treatment works, and (ii) any anticipated impact of the change on the quality or quantity of effluent to be discharged from the POTW.

Information required (note if estimated [est.] or unknown [unk.]):

a.	Is the wastewater to be accepted subject to a Federal Effluent Limitation Guideline (ELG)? (See EPA Industry Effluent Guidelines)	Yes	No
i.	If yes, does that wastewater meet the Pretreatment Standards for that ELG?	Yes	No
b.	Is the wastewater to be accepted from a Significant Industrial User? (See 40 CFR 403.3(v))	Yes	No
c.	What volume of wastewater is to be accepted? Note if it is to be continuous discharged, trucked, or batch discharged (what frequency).	MGD
Continuous	Trucked	Batch	Frequency?
d.	If the wastewater to be accepted is to be batch discharged, is there a potential for a slug load potentially causing a plant upset, pass through or interference?	Yes	No
e.	Is your wastewater treatment plant’s hydraulic capacity adequate to accept this additional wastewater?	Yes	No
f.	Provide analytical data on a representative sample of the wastewater to be accepted for CBOD5, TSS, fecal coliform (if deemed pertinent), NH3-N, and Total Phosphorous.
g.	Will your wastewater plant be organically overloaded by the acceptance of this wastewater?	Yes	No
h.	Is there the potential for your wastewater plant’s effluent to fail whole effluent toxicity?	Yes	No
i.	What was the principal reason the requestor asked to discharge their wastewater to your wastewater collection system?
j.	What is the name and physical address of the entity wishing to discharge their wastewater to your system?

This notification must be accompanied by the following certification statements by a duly authorized representative of the POTW:

“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.

I further certify that our NPDES Permit limits and/or conditions will not be violated upon the acceptance of the aforementioned wastewater.”

Typed or Printed Name:	Title:
Signature:	Date:

This notification must be sent to:

Arkansas Department of Environmental Quality

Water Division, NPDES Permit Section

5301 Northshore Drive

North Little Rock, AR 72118-5317

Or by email to:

Water.Permit.Application@adeq.state.ar.us