3800-PM-BPNPSM0027b
Application
7/2014
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
APPLICATION FOR PERMIT AMENDMENT
Before completing this form, read the step-by-step instructions provided in this application package. This application
may be used only by permittees holding an individual NPDES permit.
Type of Amendment Requested:
DEP USE ONLY
Date Received & General Notes
Minor Amendment
Major Amendment
Existing Permit Information:
Facility Name:
NPDES Permit No.
Municipality:
Effective Date:
County:
Expiration Date:
Facility Type / Fee Category:
SRSTP/SFTF
Major Sewage with CSO
Municipal Stormwater (MS4)
Minor Sewage < 0.05 MGD
Minor IW without ELG
IW Stormwater
Minor Sewage ≥ 0.05 MGD and < 1 MGD
Minor IW with ELG
CAAP
Major Sewage ≥ 1 MGD and < 5 MGD
Major IW < 250 MGD
CAFO
Major Sewage > 5 MGD
Major IW ≥ 250 MGD
Pesticides
AMENDMENT INFORMATION
Detailed Explanation of Permit Amendment Request (see Instructions and attach additional sheets if necessary):
CLIENT/OPERATOR INFORMATION
DEP Client ID#
Client Type/Code
Organization Name or Registered Fictitious Name
Employer ID# (EIN)
Dun & Bradstreet ID#
Individual Last Name
First Name
MI
SSN
Client Mailing Address Line 1
Client Mailing Address Line 2
Client Mailing Address City
State
ZIP+4
-1-
Suffix
Country
3800-PM-BPNPSM0027b
Application
7/2014
Client Contact Last Name
First Name
Client Contact Title
MI
Suffix
Phone
Ext
E-mail Address
FAX
COMPLIANCE HISTORY REVIEW
Is the facility owner or operator in violation of any DEP regulation, permit, order or
schedule of compliance at this or any other facility?
YES
NO
If YES, list each permit, order, regulation or schedule that is in violation and provide compliance status of the
permitted activity (use additional sheets to provide information on all permits).
Permit Program
Permit No.
Brief Description of Non-Compliance:
Steps Taken to Achieve Compliance
Current Compliance Status:
Date(s) Compliance Achieved
In Compliance
In Non-Compliance
CERTIFICATION
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 gathered and evaluated 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. See Pa. C.S. § 4904 (relating to unsworn
falsification).
Name (type or print legibly)
Official Title
Signature
Date
-2-