Adem Form 187 - National Pollutant Discharge Elimination System (Npdes) Permit Application Supplementary Information For Industrial Facilities

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NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) PERMIT APPLICATION
SUPPLEMENTARY INFORMATION FOR INDUSTRIAL FACILITIES
ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
WATER DIVISION – INDUSTRIAL SECTION
POST OFFICE BOX 301463
MONTGOMERY, ALABAMA 36130-1463
INSTRUCTIONS: APPLICATIONS SHOULD BE TYPED OR PRINTED IN INK AND SUBMITTED TO THE DEPARTMENT IN
DUPLICATE TO THE ADDRESS ABOVE. IF INSUFFICIENT SPACE IS AVAILABLE TO ADDRESS ANY
ITEM, PLEASE CONTINUE ON AN ATTACHED SHEET OF PAPER.
PLEASE MARK N/A IN THE
APPROPRIATE BOX WHEN AN ITEM IS NON-APPLICABLE TO THE APPLICANT.
PURPOSE OF THIS APPLICATION
INITIAL PERMIT APPLICATION FOR NEW FACILITY
INITIAL PERMIT APPLICATION FOR EXISTING FACILITY
MODIFICATION OF EXISTING PERMIT
REISSUANCE OF EXISTING PERMIT
____ REVOCATION & REISSUANCE OF EXISTING PERMIT
1. Facility Name:
a. Operator Name:
b. Is the operator identified in 1.a., the owner of the facility?
Yes
No
If no, provide the name and address of the operator and submit information indicating the operator’s scope of responsibility
for the facility.
2. NPDES Permit Number
AL ___ ___ ___ ___ ___ ___ ___
3. SID Permit Number (if applicable): IU
-
-
4. NPDES General Permit Number (if applicable)
ALG ___ ___ ___ ___ ___ ___ ___
5. Facility Physical Location: (Attach a map with location marked; street, route no. or other specific identifier)
Street:
City:
County:
State:
Zip:
Facility (Front Gate) Latitude: _________________________
Longitude: _________________________
6. Facility Mailing Address (Street or Post Office Box):
City:
State:
Zip:
ADEM Form 187 08/16 m4
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