OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
AFFIDAVIT OF NO DISCHARGE
This form applies to the following types of facilities:
_________________________
1. Wastewater treatment facilities
(CF Number)
a. Total retention by evaporation
OK00____________________
b. Total retention by an approved Land Application Program
(NPDES No. if Applicable)
2. Water Plants that treat backwash water by re-cycling or evaporation lagoons.
3. Swimming Pools that treat wastewater by evaporation in total retention lagoons.
4. Dairy farm wastewater treatment facilities.
5. Abandoned wastewater facilities.
1. FACILITY NAME: _________________________________________________________________________________________________________________
2.
FACILITY ADDRESS:______________________________________________________________________________________________________________
3.
FACILITY COUNTY:__________________________________LEGAL ( ¼ ¼ ¼ Sec., T, R)______________________________________________________
4.
OWNER NAME AND ADDRESS:_____________________________________________________________________________________________________
5.
CONTACT PERSON:__________________________________PHONE:____________________________TITLE:____________________________________
6. MAILING ADDRESS: ______________________________________________________________________________________________________________
7.
TYPE OF FACILITY:
WASTEWATER PLANT ( ) WATER PLANT ( ) SWIM. POOL ( )
DAIRY FARM ( )
OTHER ( )
8.
TYPE OF TREATMENT:
EVAPORATION ( )
LAND APPLICATION ( )
OTHER ( )
9.
THIS FACILITY IS:
PUBLICLY OWNED ( )
PRIVATELY OWNED ( )
10. THIS FACILITY WAS DESIGNED AS A:
( ) TOTAL RETENTION FACILITY WITH NO OUTFALL STRUCTURE SUCH AS AN OUTFALL BOX OR SLUICE GATE
( ) DISCHARGING FACILITY
11. HAS THIS FACILITY EVER HAD AN OPDES PERMIT TO DISCHARGE OR HAS THERE BEEN APPLICATION MADE FOR A PERMIT?
YES ( ) NPDES NO OK00____________
NO ( )
12. HAS THIS FACILITY EVER HAD AN OUTFALL BOX OR SLUICE GATE THAT COULD RESULT IN A WASTEWATER DISCHARGE? YES ( ) NO ( )
IF YES TO 12., GIVE A BRIEF EXPLANATION OF ANY CONSTRUCTION OR REUSE OF THE WASTEWATER THAT HAS RESULTED IN A
CHANGE OF DISCHARGE STATUS __________________________________________________________________________________________________
13. DOES THE SWIMMING POOL, MOBILE HOME PARK, DAIRY FARM, ETC. CONTINUE TO GENERATE WASTEWATER ? YES ( ) NO ( )
IF YES TO 13., ARE THERE HOLDING PONDS AND/OR A LIFT STATION AT THE SITE? YES ( ) NO ( )
WHERE IS THE WASTEWATER TREATED? ____________________________________________________________________________________________
( ) TOTAL RETENTION FACILITY
( ) DISCHARGING FACILITY – NPDES NUMBER OK00________________________________
IF NO TO 13., HAS THE FACILITY OR ENTITY GENERATING THE WASTEWATER BEEN ABANDONED ? YES ( ) NO ( )
I, (Name) ________________________________________________, (Title) ____________________________________CERTIFY THAT THE ABOVE
INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT THE (Facility) ____________________________________________________
DOES NOT DISCHARGE WASTEWATER TO ANY WATERS OF THE STATE NOR DOES IT DISCHARGE TO ANY DITCH OR LAND AREA THAT
COULD RESULT IN A DISCHARGE TO WATERS OF THE STATE. I CERTIFY THAT IN THE EVENT OF A HYDRAULIC LOAD INCREASE OR OTHER
FACTORS OCCUR THAT WILL CAUS E THE FACILITY TO DISCHARGE WASTEWATER, AN APPLICATION FOR A PERMIT TO DISCHARGE WILL BE
EXECUTED AT LEAST 180 DAYS PRIOR TO AN EXPECTED DISCHARGE. I UNDERSTAND THAT ALL UNEXPECTED UNPERMITTED DISCHARGES
MUST BE REPORTED TO THE APPROPRIATE AGENCIES IMMEDIATELY.
I REQUEST THAT THE NPDES PERMIT/APPLICATION NUMBER OK00____________________________ BE DISCONTINUED.
APPLICANT REPRESENTATIVE : _______________________________________________________TITLE :___________________________________________
Subscribed and sworn to before me this _____ day of _________________________________, 19 _____.
NOTARY PUBLIC : ___________________________________________________________My commission expires: ______________________________________
Confirmed by Environmental Specialist: ____________________________________________R.S. NO. ___________________DATE:_________________________
Oklahoma Department of Environmental Quality – 707 N. Robinson St., P. O. Box 1677, Oklahoma City, OK 73101-1677
DEQ Form No. 530 E (9-98)