Legal Discharge Permit Application

LEGAL DISCHARGE PERMIT APPLICATION

Applicant Name:   Issuing Authority:   Date of Application:

Recitals

WHEREAS, the Issuing Authority has the statutory jurisdiction to regulate and authorize discharges of wastewater, stormwater, and other effluents into public sewers, waters, or treatment systems and to impose conditions to protect public health and the environment; and

WHEREAS, the Applicant operates or will operate a facility, described in this application, from which a regulated discharge is proposed and seeks a permit authorizing such discharge subject to terms, monitoring and reporting requirements, and corrective measures; and

WHEREAS, the Issuing Authority requires an executed application, supporting documentation, and certifications to evaluate potential impacts and establish enforceable conditions;

NOW THEREFORE, in consideration of the representations and agreements contained herein, Applicant submits this application and agrees to the terms and conditions set forth below.

1. Definitions

For purposes of this application and any permit issued hereunder, the following definitions shall apply: "Discharge" means any direct or indirect release of pollutants from a point source; "Permit" means any authorization, license or equivalent control document issued by the Issuing Authority; "Applicant" means the person or legal entity identified above and includes its agents, successors and assigns.

2. Applicant and Facility Information

Individual    Corporation    Municipality/Public Utility    Other

3. Facility and Discharge Description

Proposed Commencement of Discharge:   Average Flow (gpd):   Maximum Daily Flow (gpd):

Is this a temporary or pilot discharge? Yes    If temporary, anticipated duration:

4. Supporting Documentation and Attachments

The Applicant certifies submission of the following documents with this application (check all submitted):

Site plan showing discharge point(s)
Process flow diagram
Representative analytical results
Monitoring and sampling plan
Engineering/corrosion control report

5. Monitoring, Reporting and Compliance

If a permit is issued, Applicant shall, as a condition of authorization, implement a monitoring and reporting program acceptable to the Issuing Authority. Monitoring shall include sampling locations, frequency, analytes, chain-of-custody procedures, and quality assurance/quality control sufficient to demonstrate compliance. Applicant agrees to allow access to the facility for inspection and sampling by authorized representatives of the Issuing Authority at reasonable times.

6. Fees, Financial Responsibility and Corrective Measures

Applicant acknowledges that application processing, permit issuance, inspection, monitoring and enforcement may be subject to fees and costs. Payment of fees does not relieve the Applicant of the obligation to comply with permit conditions. Applicant shall be financially responsible for corrective actions, remediation, and any penalties resulting from a violation of permit terms.

Applicant agrees to provide security or financial assurances if required by the Issuing Authority: Acknowledged

7. Liability, Indemnity and Insurance

Applicant shall indemnify, defend and hold harmless the Issuing Authority and its officers, employees and agents from and against any and all claims, liabilities, losses, costs and expenses arising out of or resulting from the Applicant’s discharge or failure to comply with permit conditions, except to the extent caused by the gross negligence or willful misconduct of the Issuing Authority. Applicant shall maintain insurance coverage adequate to cover potential liabilities and shall furnish proof upon request.

8. Certifications and Applicant Authorization

The undersigned certifies under penalty of law that the information provided in this application and accompanying documents is true, accurate and complete to the best of the signatory's knowledge. The signatory further certifies that they are authorized to submit this application on behalf of the Applicant and to bind the Applicant to the terms and conditions of any permit issued in reliance upon this application.

9. Notices

All notices required or permitted under this application or any permit issued in reliance hereon shall be in writing and shall be deemed given when delivered in person or when sent by certified mail, return receipt requested, to the addresses provided in this application or to such other address as either party designates in writing.

10. Governing Law; Entire Agreement; Severability; Amendments

This application, and any permit issued pursuant hereto, shall be governed by the laws of the jurisdiction of the Issuing Authority. This application constitutes the complete written agreement between the Applicant and the Issuing Authority regarding the matters herein and supersedes all prior representations. If any provision is held invalid, the remainder shall continue in full force and effect. No amendment or waiver shall be effective unless in writing and signed by both parties.

11. Certification of Truth and Acknowledgement of Enforcement

By signing below, Applicant confirms that they have read and understand the requirements and enforcement provisions applicable to discharges and consent to entry and inspection by the Issuing Authority to verify compliance. The Applicant acknowledges that false statements or omissions may subject the Applicant to civil or criminal penalties.

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