Wyoming Pollutant Discharge Elimination System (WYPDES)

                           Department of Environmental Quality
                           Application for Permit to Discharge Wastewater for:

                           Industrial operations, Form G Application Instructions
                           New: 05-21-08

The industrial operations, Form G, is a permit application to discharge wastewater for new and existing manufacturing,
commercial, mining, and silviculture operations. This form is not for those applicants of public owned treatment works, coal
mining or concentrated animal feeding operations or aquatic animal production facilities.

Mail the application to:

         WYPDES Permits Section
         Department of Environmental Quality/WQD
         122 West 25th Street, Herschler Building, 4W
         Cheyenne, WY 82002

When to file: Please file 180 days before your present WYDPES permit expires or 180 days prior to startup.

Fees: Permits issued under the WDEQ (Wyoming Department of Environmental Quality) program are subject to an annual $100
permit fee as long as the permit is active. The annual billing cycle is based on the calendar year. There is no need to pay the
fee with the application. All permit fees are invoiced after January 1st of each year.

General Application Instructions:

    1.   Please provide as much information as possible on the application form. Additional spaces may be inserted in the
         application form to accommodate additional information. Please keep attachments to a minimum.

    2.    Please provide a response to ALL items, even if it is to indicate that the item is “not applicable”. Leaving items blank
         may result in the application being returned as incomplete.

    3.   Do NOT separate any portion of the application, including the following tables. All supplemental information should be
         attached following the permit application. Use of cover sheets should be restricted to supplemental information ONLY.

    4.   Do not staple or bind any of the permit application materials. Only binder clips or paper clips should be used to
         separate or bind materials.

    5.    While the WDEQ allows permittees to reference previously completed works, please ascertain that the item being
         referenced is available to WDEQ personnel for review during the permit application process. WDEQ personnel may
         request copies of referenced works if not available for review. Information easily incorporated into the permit
         application may not be referenced (for example, the names and addresses of land owners).

    6.   Please place all oversized pages at the back (END) of the permit application materials. This aids in scanning and/or
         copying of the permit application materials. If necessary to attain adequate legibility, tables may be enlarged and
         submitted on paper other than 8.5 X 11. Use whatever size necessary to achieve adequate legibility.

    7.   If at all possible, the WDEQ would appreciate the inclusion of an electronic version of the permit application, either on
         CD or floppy diskette, including any supplemental permit application materials. Inclusion of an electronic version of the
         permit application speeds permit processing.

    8.    If at all possible, the WDEQ would appreciate the inclusion of an electronic version of the outfall location table (Table
         1 in the permit application), in either Word (.doc) or Excel (.xls) format for inclusion in the draft permit document.
         Inclusion of this information speeds permit drafting.

    9.   Please include unique footer information on each page of this application and on all supporting documentation using the
         following format: “Company Name/ Application type (NEW, MOD, RENEWAL)/ If applying for a renewal or
         modification, use of the existing WYPDES permit number is sufficient as a unique footer identifier.
         For example: “Amy’s Company/ Renewal/ WY000000”
Specific items:

Item 1. Application type: If the application type is renewal or major modification, please provide the permit number “WY000000”
and expiration date “12/31/2018”.

Item 2. Provide the general township(s) or range(s) of the facility location.

Item 3. Provide a street address if appropriate. If not, indicate that the item is “not applicable” or N/A.

Item 4. Receiving waters: This item requires the permittee to provide the written description of waters of the state from the
mainstem to the outfall location. For example: “Powder River via Wild Horse Creek via Middle Prong Wild Horse Creek via an
unnamed ephemeral tributary” or “North Platte River via Deer Creek”.

Item 5. Facility Name: This is the facility name that will appear on your WYPDES permit.

Item 6. SIC Code: “Standard Industrial Classification Manual” or SIC codes numbers are industrial descriptions which are
prepared by the Executive Office of the President, Office of Management and Budget. The SIC codes are listed on our website.

List in descending order of significance, the four 4-digit standard industrial classification (SIC) codes which best describe your
facility in terms of the principal products or services you produce or provide. Also, specify each classification in words. These
classifications may differ from the SIC codes describing the operation generating the discharge.

Item 7. Permittee Contact Information: This is the company, organization, or individual that has day-to-day supervision and
control of activities occurring at the facility. Also, preference is referring to which form of communication do you prefer (e.g.
phone, email, fax, etc.)

Item 8. Enter the appropriate box to indicate the legal status of the applicant. Indicate “public” for facility solely owned by local
government(s) such as a city, town, county, etc.

Item 9. Enter the appropriate box to indicate the applicant status as owner and/or operator. Check all boxes that apply.

Item 10. Operator Contact Information: This is the individual that has day-to-day supervision and control of activities occurring at
the facility. This may be the same as permittee.

Item 11. Briefly describe the nature of your business (e.g. products produced or services provided).

Item 12. Describe modification requests:

         a. Please provide either currently underway or anticipated projects over the next five years, which will affect the quality
         of the discharge. Note major modification applications for permits within six months of their expiration date will also be
         processed as renewals.
         b. For each change or improvement, provide projected dates, as accurately as possible

         c. If you check “yes” to this question, complete all parts of Table 3.

Item 13. Landowner or lessee’s contact information: Please provide the owners of the surface rights on whose land the
         discharge occurs. In cases where the land is owned by the state or federal government but surface rights are leased
         to a private individual, provide the lessee’s contact information.

Item 14. Facility Flow Diagram: An example of an acceptable line drawing is below. The line drawing should show the route
         taken by the water in the facility from intake to discharge. Show:

             a.   All operations contributing wastewater, including process and production areas, sanitary flows, cooling water,
                  and stormwater runoff.
             b.   All point of discharge to sanitary sewer, storm sewers, surface waters, septic tanks, injection wells, and/or floor
             c.   Indicated sources of intake water
             d.   Operations contributing wastewater to the effluent
             e.   Wastewater treatment units along with each discharge outfall

             f.   Water balance on the schematic line drawing showing average flows between intakes, operations, treatment
                  units and outfall(s).

Item 15. Outfall location: Table 1. Provide all the information requested in the table for each proposed discharge point (outfalls).
         If proposing changes (a major modification) to an existing facility, clearly indicate the desired changes on the table.
         Additional tables may be attached. Use the format provided.

         Notes:The mainstem is the closest perennial water (class 2). Stream distance from the outfall to the mainstem should
         be measured in stream miles versus as “the crow flies”. Latitude and longitudes should be accurate to a minimum of 5
         decimal places and using North American Datum 1983 (NAD 83).

Item 16. Table 2: List all sources of wastewater to each outfall.

         Column A of Table 2. Operation(s) Contributing Flow
         Describe all operations contributing wastewater to the effluent including process wastewater, sanitary wastewater,
         cooling water, and storm water runoff. Description may be in general terms (for example: “dye-making reactor” or
         “distillation tower”).

         Column B of Table 2. Average Flow (MGD)
         Provide the average flow contributed by each operation in million gallons per day (MGD). You may estimate the flow
         contributed by each source if no data are available.

         Column C of Table 2. Treatment

         Briefly describe the treatment for these wastewaters prior to discharge, including the ultimate disposal of any solid or
         liquid wastes not discharged. You should select the proper treatment code from Attachment B (Physical, chemical, and
         biological treatments processes, other processes and sludge treatment and disposal processes) to be filled in column 3
         for each treatment unit. If no codes corresponds to a treatment unit you list, please describe the type of treatment

          If there are any flocculants (settling agents or chemical additives) that are used to treat water prior to discharge,
         provide a list of the chemical manufacturer, and purpose. Please include the Material Safety Data Sheets (MSDS) with
         the application. If you are applying for a permit for a privately owned treatment works, you must also identify all of your
         contributors in an attached listing. The average flow of point sources composed of storm water may be estimated. The
         basis for the rainfall event and the method of estimation must be indicated.

Item 17. Indicate whether the discharge will be continuous, intermittent and/or seasonal, or no discharge for each outfall. If the
         discharge is to be intermittent and/or seasonal, for each outfall provide I) Number of times per year the discharge is to
         occur II) Anticipated duration of each discharge III) Anticipated flow of each discharge IV) Months in which discharge is
         expected to occur.

Item 18. Facility map: Attach a description and a clear, legible, detailed topographic map of the discharging facility that extending
         one mile beyond the property boundaries of the source. Include the following:
    a.   A legend
    b.   Well locations where fluids from the facility are injected underground
    c.   Retention Ponds
    d.   Each intake sites
    e.   Discharge points (outfalls)
    f.   Monitoring and/or compliance points
    g.   Hazardous waste treatment, storage, or disposal facilities
    h.   Immediate receiving streams
    i.   Section, Township, and Range information
    j.   Wells, springs, other surface water bodies, drinking water wells, and surface water intake structures listed in public
         records, or otherwise known to the applicant in the map area.

Item 19. Describe the control measures at the outfalls that will be implemented to prevent erosion to receiving water channel.

Item 20. Production: Production refers to those goods which the proposed facility will produce, not to “wastewater” production.
         This information is only necessary where production-based new source performance standards (NSPS) or effluent
         guidelines apply to your facility. Your estimated production figures should be based on a realistic projection of actual
         daily production level (not designed capacity) for each of the first three operating years of the facility. This estimate
         must be a long-term-average estimate (e.g., average production on an annual basis). If production will vary depending
         on long-term shifts in operating schedule or capacity, the applicant may report alternative production estimates and the
         basis for the alternate estimates.

         If known, complete 20c. For example, if the applicable NSPS is expressed as “grams of pollutant discharged per
         kilogram of unit production,” then report maximum “Quantity per day” in kilograms. If you do not know whether any
         NPSP or effluent guideline applies to your facility, report quantities in any unit of measurement known to you. If an
         effluent guideline or NSPS specifies a method for estimating production, that method must be followed.

         There is no need to conduct new studies to obtain these figures; only data already on hand are required. You are not
         required to indicate how the reported information was calculated.

Item 21. Intake and Effluent Characteristics:

         a.   Provide a brief narrative description of the intake water source and amount of water in GPD.
         b.   Attachment A, Table I provides a list of industrial categories. Please select which industrial category your facility
              falls under.

         c.   Complete Table 4.

                  i. Based on Attachment A, Tables II-V, indicate if there are any pollutants present in the outfalls solely as a
              result of the presence in the intake water. If you would expect a pollutant to be present solely as a result of its
              presence in your intake water, you must mark “believe present” but you are not required to analyze for that

              For Table 4:
              Column A: The applicant must provide a list of any constituents listed in Attachment A, Tables II-V which the
              applicant currently uses or manufactures as an intermediate or final product or by product. If any additional
              constituents are known to be used or manufactured and not identified in Attachment A, Tables II-V, list those as
              well. Remember to base your determination of whether a pollutant will be present in your discharge on your
              knowledge of the facility’s raw materials, maintenance chemicals, intermediate and final products, byproducts, and
              any analyses of your effluent or of any similar effluent. You may also provide the determination and the estimates
              based on available in-house or contractor’s engineering reports or any other studies performed on the facilities.

              Column B & C: Provide the approximate pollutant amount as the maximum daily and average daily value. For new
              facilities only, the applicant does not need to provide the amount from Attachment A, Table V (certain hazardous
              substances) if the facility has no quantitative estimates is already available.

              Column D: Indicate which source the estimated values were based upon. For example engineering study, actual
              data from plot plants, estimated from other engineering studies, data from other similar plants, best professional
              estimates, etc.

d.     Table 5     For existing facilities, attach the quantitative data of at least one analysis from every pollutant in this
       table for each outfall. For new facilities, provide estimated values and source of information for each parameter in
       Table 5.

       The administrator may waive the reporting requirements for pollutants listed in above if the applicant has
       demonstrated that such a waiver is appropriated because information adequate to support issuance of a permit can
       be obtained with less stringent requirements.

e.     Table 6 Quantitative data: If you marked in Table 4 any pollutant which is limited either directly, or indirectly but
       expressly, in an effluent limitation guideline, you must provide the results of at least one analysis for that pollutant.
       WDEQ may require additional information and/or analysis of these pollutants at a later date. Each applicant must
       report quantitative data for each outfall containing process wastewater with the following exceptions:
          i.      For every pollutant discharged which is not so limited in an effluent limitations guideline, the applicant
                  must either report quantitative data or briefly describe the reasons the pollutant is expected to be
          ii.     For every pollutant expected to be discharged in concentrations of 10 µg/L or greater the applicant must
                  report quantitative data. For acrolein, acrylonitrile, 2,4 dinitrophenol, and 2-methyl4,6 dinitrophenol,
                  where any of these four pollutants are expected to be discharged in concentrations of 100 µg/L or
                  greater, the applicant must report qualitative data. For every pollutant expected to be discharged in
                  concentrations less than 10 µg/L or in the case of acrolein, acrylonitrile, 2,4 dinitrophenol, and 2-methyl-
                  4,6 dinitrophenol, in concentrations less than 100 µg/L, the applicant must either submit quantitative data
                  or briefly describe the reasons the pollutant is expected to be discharged.

The following applies to Item 21.d., 21.e. and 21.g.
     Reporting Intake Data: You are not required to report pollutants or parameters present in the intake unless you wish
to demonstrate your eligibility for a “net” effluent limitation for these pollutants or parameters, that is, an effluent
limitation adjusted to provide allowance for the pollutants or parameters present in your intake water. If you wish to
obtain credits for pollutants or parameters present in your intake, please insert an attachment with a short statement of
why you believe you are eligible (see 40 CFR 122.45(g)).

All estimated pollutant or parameter levels must be reported as concentration and as total mass (except for discharge
flow, pH, and temperature). Total mass is the total weight of pollutants discharged over a day. Use the following
abbreviations for units:

Concentration                                       Mass
ppm         parts per million                       lbs       pounds
mg/L        milligrams per liter          ton       tons (English tons)
ppb         parts per billion                       mg        milligrams
µg/L        microgram per liter           g         grams

kg          kilogram                               T         tones (metric tons)

     Sampling procedure for effluent samples: For pH, temperature, cyanide, total phenols, residual chlorine, oil and
grease, fecal coliform, fecal streptococcus and E.coli, grab samples must be used. For all other pollutants 24-hour
composite samples must be used. However, a minimum of one grab sample may be taken for effluents from holding
pond or other impoundments with a retention period of greater than 24-hours. In addition, the administrator may waive
composite sampling for any outfall for which the applicant demonstrates that the use of an automatic sampler is
infeasible and that the minimum of four grab samples will be a representative sample of the effluent being discharged.

     Lab Results: When quantitative data for a pollutant are required, the applicant must collect a sample from the facility
being proposed for renewal or modification. The analyses must be conducted in accordance with approved EPA test
procedures (40 CFR Part 136). Include a signed copy of your lab report that includes the following:

        i. Detection limits
        ii. Results of each of the chemical parameters at the chemical state given below
       iii. Quarter/quarter, section, township, and range of the sample collection location
       iv. Time and date of sample collection
        v. Time and date of analysis for each parameter
       vi. Analyst’s initials for each parameter
       vii. Detection limit for each parameter as achieved by the laboratory
      viii. WYPDES permit number and outfall number, where the sample was collected

     Small Business Exemption: If you are a “small business”, you are exempt from the reporting requirements to the
 GC/MS fractions of Table 6 only. You may qualify as a “small business” if the gross total annual sales average less
 than $100,000 per year (in second quarter 1980 dollar). If you are a “small business”, you may submit projected
 sales or production figures to qualify for this exemption. The sales or production figures you submit must be for the
 facility which is the source of the discharge. The data should not be limited only to production or sales for the
 process(es) which contribute to the discharge, unless those are the only processes at your facility. For sales data,
 where intracorporate transfers of goods and services are involved, the transfer price per unit should approximate
 market prices for those goods and services as closely as possible. If necessary, you may index your sales figures to
 the second quarter of 1980 to demonstrate your eligibility for a small business exemption. This may be done by using
 the gross national product price deflator (second quarter of 1980=100), an index available in “National Income and
 Product Accounts of the United States” (Department of Commerce, Bureau of Economic Analysis).

 Again the small business exemption applies to the GC/MS fractions (Attachment A, Table II) only. Even if you are
 eligible for a small business exemption, you are still required to provide information on metals, cyanide, total phenols
 (Attachment A, Table III) and dioxins, as well as all conventional and nonconventional pollutants (Attachment A, Table
 IV) and those listed in Table 5 of this application.

           For new facilities, please note that no later than two years after you begin discharging from the proposed facility, you
           must complete and submit the pollutant(s)from Attachment A, Tables II-V which you know or have reason to believe
           are or may be discharged from any outfall(s). However, you need not complete those portions of Item 21 requiring
           tests which you have already performed under the discharge monitoring requirements of your WYPDES permit. In
           addition, the WDEQ may waive the requirements under Item 21 if the permittee make the demonstration required
           under 40 CFR 122.22(g)(7)(i)(B) and 122.21(g)(9).

          f.   Self explanatory.
          g.   Self explanatory.

Item 22. This applies to existing facilities only.
Item 23. This applies to new facilities only.
Item 24. Self explanatory
Item 25. List all active permits or construction approvals received or applied for by the applicant for the following programs:
                         Hazardous Waste Management program under the Resource Conservation and Recovery Act.
                         Underground injection control program under the Safe Drinking Water Act.
                         WPDES program under Clean Water Act.
                         Prevention of Significant Deterioration program under the Clean Air Act.
                         Non-attainment program under the Clean Air Act.
                         National Emission Standards for Hazardous Pollutants under the Clean Air Act.
                         Section 404 of the Clean Water Act.
                         Impoundments and/or Appropriation of Surface Water under the State Engineer’s Office
                         Reservoirs under the Oil and Gas Conservation Commission.
                         Other relevant local, state, or federal environmental permits.

                                                                                      Official Use only
                              Wyoming Pollutant Discharge Elimination System (WYPDES) Date Received:

                              Department of Environmental Quality
                              Application for Permit to Discharge Wastewater for:

                              Industrial operations, Form G
                              New: 05-21-08

 Please print or type. Submission of illegible materials will result in return of the application to
    the applicant.
 All items must be completed accurately and in their entirety or the application will be
    deemed incomplete and the processing will be delayed or application returned.
      1. Check the box of the applicant type of application being applied for:
 An original signature corresponding to theis required. Faxes cannot be accepted.



                           Major modification                     Permit number _____________            Expiration Date:

        2.   General Facility Location:         Township(s) _____________________           Range(s) ____________________

        3.   Street address if applicable: _________________________________________________________________

        4.   Receiving Waters __________________________________________________________

        5.   Name of the facility producing the discharge


        6. Standard Industrial Classification code (SIC Code) and description: _________________________

        7.   Permittee and Consultant (if applicable) Contact Information:

        Permittee Contact Name                                               Consultant Contact Name

        Company Name                                                         Company Name

        Mailing Address                                                      Mailing Address

        City, State, and Zip Code                                            City, State, and Zip Code

                                                                                                                            Page 1 of 11
Telephone Number                                                    Telephone Number

E-Mail Address                                                      E-Mail Address

Preference for contact:                                             Preference for contact:

8. Status of applicant:           Federal     State       private      public       Other ________________

9. Status of applicant (check more than one):          Owner          Operator

10. Operator Information:

                                    Operator Name

                                    Operator Certification Number/Class

                                    Mailing Address

                                    City, State, and Zip Code

                                    Telephone Number

                                    E-Mail Address

11.   Please include a brief description of the nature of the business conducted at this facility and principal products or services
      provided by the facility.

12. a. Describe modification requests:

      b.   For each change or improvement, provided projected dates, as accurately as possible, for completion of each step
           listed below:

           1.   Begin Construction: ____________________________

                                                                                                                          Page 2 of 11
          2.   End Construction: ______________________________
          3.   Begin Discharge: ______________________________
          4.   Operational Level Attained:_______________________

    c.    For renewals and modifications, are you scheduled for the construction, upgrading, or operations of wastewater
          treatment equipment or practices or any other environmental programs which may affect the discharges described in
          this application? This includes, but not limited to, permit condition, administrative or enforcement orders, enforcement
          compliance schedules letters, stipulations, court orders, and grant or loan conditions.
                                             YES                                    NO

         If yes, please fill out Table 3.

13. Landowner or lessee’s contact information:
Landowner #1 Name                                                   Landowner #2 Name

Mailing Address                                                     Mailing Address

City, State, and Zip Code                                           City, State, and Zip Code

    (additional spaces may be added as necessary)

14. Facility Flow Diagram:

    Please provide a schematic line drawing showing the water flow through the facility. See application instructions.

15. Outfall location: Complete the attached Table 1.

16. Outfall Characterization: Complete the attached Table 2. See application instructions for details.
    a. Will any flocculants (settling agents or chemical additives) be used to treat water prior to discharge?

                YES                                    NO

    If yes, list here the chemical name, manufacture, and purpose. Include MSDS

17. Is discharge (check one):

                A. Continuous
                B. Intermittent and/or seasonal

                                                                                                                         Page 3 of 11
                 C. No Discharge

     If intermittent and/or seasonal, the following information for each outfall shall be provided:
                    (I) Number of times per year the discharge is to occur.
                    (II) Anticipated duration of each discharge.
                    (III) Anticipated flow of each discharge.
                    (IV) Months in which discharge is expected to occur.

18   Facility map: Attach a description and a clear, legible, detailed topographic map of the discharging facility. For specifics,
     follow the application instructions.

19. Describe the control measures that will be implemented to prevent significant damage to or erosion of the receiving water
          channel at the outfall(s)____________________________________________________________

20. Production: For new industrial applicants only.
            a.      Does an effluent guideline limitation or standard apply to your facility (e.g. metal finishing, fertilizer
                    manufacturing, etc) as stated under Section 306 of the Clean Water Act?

                            YES             (complete item 20B below)                            NO (complete Question 21)

            b.      Are the limitations in the applicable effluent guideline express in terms of production or other measure of

                             YES            (complete table below)                               NO (complete Question 21)

             Affected outfalls                  Quantity per day             Units of Measure                Specify Operation, Product,
                                                                                                             or Materials

21. Intake and Effluent Characteristics
            a.      Water Source Information:

                      City Supply (specify the source and gallons per day GPD):_____________________________________
                      Well Supply (specify the source and gallons per day GPD):______________________________________

                                                                                                                                 Page 4 of 11
           Surface water (specify the source and gallons per day GPD):____________________________________
           Other (specify the source and gallons per day GPD):___________________________________________

b.   Which (if any) industrial category listed in Attachment A, Table I does your facility fall under?


c.   Complete the attached Table 4. See application instructions for details.

              i. Are there any pollutants (listed in Attachment A, Tables II-V) present in the discharge solely as a
                 result of the presence in intake water?
                       YES                                            NO

d.   Table 5. Provide the results of at least one analysis from every pollutant in this table for each outfall. See
     application instructions for details.

e.   Table 6. Quantitative data: Provide the result of water analyses for a sample collected from the facility. See
     application instructions for more details.

f.   Do you have any knowledge or reason to believe that any biological test for acute or chronic toxicity has been
     made on any of your discharges or on receiving water in relation to your discharge within the last three

                                  YES                                           NO

     If yes, identify the tests and describe their purpose below:

g.   Dioxin testing: Each applicant must report qualitative data, generated using a screening procedure not
     calibrated with analytical standards for 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) if it :

     i.       Used or manufactures 2,4,5-trichlorophenoxy acetic acid (2,4,5,-T), 2-(2,4,5-trichlorophenoxy)
              propanoic acid (Silvex, 2,4,5,-TP); 2-(2,4,5-tricholorophenoxy) ethyl 2,2-dichloropropionate (Erbon);
              0,0-dimethyl 0-(2,4,5-trichlorophenyl) phosphorothioate; 2,4,5-trichlorophenol (TCP); or
              hexachlorophene (HCP); or
     ii.      Knows or has reason to believe that TCDD is or may be present in an effluent.

                                                                                                            Page 5 of 11
22. For applications for existing facilities, has the facility ever exceeded permit limits or water quality standards? If the facility
      has never discharged or has not yet been constructed, please indicate below.

                               YES                                          NO

  If the yes,

      a.   Which constituents?

      b.   Has the exceedance been addressed?

      c.   Describe how the exceedance was addressed.

23.    Report the existence of any technical evaluation concerning the applicant’s wastewater treatment, along with the name and
       location of similar plants.

24.    Other information: Any optional information the permittee wishes to have considered:

 25. Provide a listing of all active permits or construction approvals received or applied for by the applicant for the site
       described in this permit application.


Authorized signatories for this application are the following:

For corporations:              A principal executive officer of at least the level of vice president, or the manager of one or more
                               manufacturing, production, or operating facilities, provided the manager is authorized to make
                               management decisions which govern the overall operation of the facility from which the discharge

For partnerships:              A general partner.

                                                                                                                             Page 6 of 11
For a sole proprietorship:     The proprietor.

For a municipal, state,        Either a principal executive officer or ranking elected official.
federal or other public

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

      Printed Name of Person Signing                                              Title

      Signature of Applicant                                            Date

      Telephone                                                                  Fax

Section 35-11-901 of Wyoming Statutes provides that:

*All permit applications must be signed in accordance with 40 CFR Part 122.22, “for” or “by” signatures are not acceptable.

Section 35-11-901 of Wyoming Statutes provides that:
Any person who knowingly makes any false statement, representation, or certification in any application ... shall upon conviction
be fined not more than $10,000 or imprisoned for not more than one year, or both.

                                                                                                                           Page 7 of 11
TABLE 1: Outfall Location Information

                                                                                                                            (NAD 83,
                                                                Stream                                                                      (NAD 83,
    Desired                                                                                                                   decimal
                                                Mainstem       Distance                                                                      decimal
   Changes         Discharge     Immediate                                                                                   degrees
                                                 (closest        from       Quarter/                                                         degrees
 (modifications       Point       Receiving                                              Section    Township      Range     accurate to                              County
                                                 perennial    outfalls to    Quarter                                                      accurate to a
 and renewals      (Outfall) #     Stream                                                                                   a minimum
                                                  water)      mainstem                                                                     minimum of
     only)                                                                                                                     of 5
                                                                (miles)                                                                     5 decimal

Additional spaces/pages may be added if necessary. Use the format provided. Please use North American Datum 1983 (NAD 83) when reporting latitudes and longitudes.

                                                                                                                                                                       Page 8 of 11
TABLE 2: Outfall characterization

 Discharge      A.   Operation(s) contributing flow                                   C.   Treatment (Description or List codes from
                                                          B.    Average Flow
   Point                         (list)                                                             Attachment B, Table I)
(Outfall) #






    Additional spaces/tables may be included as necessary. Use the format provided.

                                                                                                                                       Page 9 of 11
TABLE 3: Improvements
      1. Affected outfalls            2. Identification of condition,                                              4. Final Compliance Date
                                               agreement, etc.          3.Brief description of project
Outfall         Source of discharge                                                                      A.   Required                  B.    Projected






                                                                                                                                                  Page 10 of 11
TABLE 4: Outfall effluent characteristics
                        B. Maximum Daily
                                             C. Average Daily value
 A.   Pollutant            Value                                      D.   Source
                                                (include units)
                           (include units)

                                                                                    Page 11 of 11
Table 5: Effluent Characteristics per outfall
You must provide the results of at least one analysis for every pollutant in this table for each outfall. See instructions for more details.

                                                          Maximum 30-day value         Long term average value
Outfall #_________         Maximum Daily Value
                                                              (if available)                  (if available)             Number of Analyses

        Parameter         Mass      Concentration      Mass         Concentration      Mass        Concentration
Biochemical Oxygen
Demand (BOD)

Total Suspended Solids

Total Organic Carbon

Chemical Oxygen
Demand (COD)

Ammonia (as N)
                         Value                      Value                            Value
Flow, discharge, MGD
                         Max           Min          Max               Min
pH (range) S.U.
                         Value                      Value                            Value
Temperature (Winter)
                         Value                      Value                            Value
Temperature (Summer)

                                                                                                                                               Page 12 of 11
Table 6: Quantitative data from pollutants on Attachment A, Table II-V
See instructions for more details.

                                               Maximum 30-day value          Long term average value
                      Maximum Daily Value                                                                 Number of Analyses
    Pollutant                                         (if available)               (if available)

                     Mass      Concentration   Mass        Concentration   Mass           Concentration

                                                                                                                 Page 13 of 11
Page 14 of 11

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