2017-02-05 Discharge Permit for Wasterwater Treatment PlantNebraska Department of Environmental Quality Ho„» Approved
Notice of Intent NOI for Authorization to Discharge Under the 06/01/2016
Nebraska ( ) g
NPDES General Permit for Storm Water Discharges Associated with
Industrial Activity (NPDES Perin itNo. NER910000)
A. Facility Operator Information
Name: Citv of Blair
IRS Employer Identification Number (EIN): 47-6006106
(The onl), alternative to having the EIN on_file it�ith the Department is, for the onmer(s) or
chief officer of the corporation to submit a United States Citizenship Attestation Form).
Mailing Address: (All correspondence 1i,ill be mailed io this address)
Street or P.O. Box: 718 S. 16th St.
City: Blair
Phone: 402-426-4191
State: NE Zip code: 68008
E-mail (optional): ars@blairnebraska.org
B. Facility Information
1. Facility Name: City of Blair Wastewater Treatment Plant
2. Street / Location: 850 East Fairview Drive
City: Blair
Zip code: 68008
County: Washington
Identify the coordinates of tile main entrance to the facility from the public roadway:
Latitude: 41.551944 ° N Longitude: 96.101389
Use decimal degrees (Example: 40.812731, 96.703260
4. List tile facility's Standard Industrial
Classification (SIC) or Activity Code(s): 4952, 221320
Refer to Appendix: D of the Industrial Storni mater General Permit (ISTD GP).for a list of
industrial activities that are covered by the permit. See Instructions.
5. Is this facility Portable and subject to relocation (as defined in Appendix A of the IS6hGP)?
❑ YES It is expected to operate at this location for months.
N NO
6. Is your site presently inactive and unstaffed?
❑ YES It is expected be inactive and unstaffed for
® NO
months.
0
C. For New or Expanded Dischargers Only
1. Complete the Endangered and Threatened Species Checklist (ISW-GP Attachment 1) and include it with
this form. (Attach the one-page checklist only.)
2. Under Part 1.1.4.5 of the ISW-GP, which Endangered Species Protection criterion applies to this facility?
❑ Criterion A ❑ Criterion B
3. According to Attachment 9 of the ISW-GP, this facility discharges to receiving waters that are designated as
State Resource Water:
❑ Class A ❑ Class B ❑ neither Class A nor Class B
D. Discharge Information
1. Storm Water Pollution Prevention Plan (SWPPP):
Provide the following information from the site's STVPPP. DO NOT attach the entire SWPPP. Attach or
provide only the information requested here:
a. Site Map as specified in Section 5.1.2 of the ISW-GP. (See instructions.)
b. List of the pollutants exposed to storm water as specified in Section 5.1.3.2 of the ISW-GP.
c. Does this site discharge storm water into a regulated municipal separate storm sewer system (MS4)?
❑ YES, discharges to MS4 belonging to:
(See list (?l1IS4s in ISTV-GP Attachment 6):
❑ The facility will submit a copy of this Notice of Intent to the MS4 identified above.
❑X NO, does not discharge to a regulated MS4
d. SWPPP Contact Person or Authorized Representative:
Name: Allen Schoemaker
Phone: 402-426-4191 Email: ars@blairnebraska.org
2. Effluent Limitation Guidelines and Process Discharges
Check all that apply:
❑ This facility has storm water discharges subject to federal effluent limitation guidelines.
(See Table I -I of the ISH,' -GP.)
❑ This facility generates industrial process wastewater or wash water as described below:
Source of Discharge Discharge Location
E. 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 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.
L Print Name: James Realph
Title: Mavor
Signature:
E-mail:
f
,e Instructions to
r ->>ho mqq, sign this Ce lification.
(optional)
Date: t { 1
...............................................................................................................................................................................................................................
2. NOI Preparer (complete if NOI1r,as prepared by someone other than the Certi,ing Official)
Prepared by: Allen Schoemaker
Company/Affiliation: Director of Public Works
Phone: 402-426-4191
E-mail: ars@blairnebraska.org