WTC Authorization Request - NYSDEC.pdf

New York State Department of Environmental Conservation Division of Water SPDES Permit - WTC Authorization Request Instructions Page

APPLICABILITY:

New or increased use and discharge of a Water Treatment Chemical (WTC) requires prior New York State Department of Environmental Conservation (NYSDEC) review and authorization. At a minimum, the permittee must notify NYSDEC in writing of its intent to change WTC use by submitting a completed WTC Form for each proposed WTC. NYSDEC will review that submittal and determine if a SPDES permit modification is first necessary or whether WTC authorization may proceed without a formal permit modification. The majority of WTC authorizations do not require SPDES permit modification. In any event, use and discharge of most WTCs cannot proceed without prior authorization from NYSDEC. NYSDEC staff may also direct you to use this form for review and authorization of other substances which could be present in wastewater.

Examples of WTCs include biocides, coagulants, conditioners, corrosion inhibitors, defoamers, deposit control agents, flocculants, scale inhibitors, sequestrants, and settling aids.

INSTRUCTIONS:

For each new or increased use of a WTC, please complete items 1.a., and 2 - 15 on the attached WTC Authorization Request. Some WTC manufacturers may be reluctant to reveal product formulations to the permittee. In those cases the WTC manufacturer may take a partially completed form from the permittee, fill in the remaining information plus items 1.b. and 16, and send the completed form directly to the permit writer. Email the completed form to: spdesapp@dec.ny.gov

SPDES ID:

Permit Class:

County:

Completing Item 8.b. (Outfall WTC Concentration) - In general, the average mg/L should be determined by dividing the average dosage in

7a by the average flow in 8a and then dividing by 8.34; the maximum mg/L should be determined by dividing the maximum dosage in 7a by the average flow in 8a and then dividing by 8.34; however, for blowdowns which are highly intermittent or are not tributary to a treatment system or some form of equalization, it may be appropriate to factor in the information in item 9 when completing this item.

Completing Item 12 (Toxicity Information) - All reported test data must represent tests conducted in accordance with current EPA toxicity testing manuals for appropriate species. Submission of acute (48 or 96 hour LC50 or EC50) and/or chronic (7 day NOEC or IC25) test results for at least one vertebrate and one invertebrate species is required.

In most cases, after reviewing the submission, NYSDEC will send a letter notifying the person identified in item 2.c and, if appropriate, to the facility inspector of the WTC authorization decision.

ADDITIONAL INFORMATION:

Please visit the NYSDEC website at http://www.dec.ny.gov/permits/93245.html for copies of this form, copies of the WTC Annual Report

Form, and additional information on WTCs.

(July 2023) http://www.dec.ny.gov/permits/93245.html mailto:spdesapp@dec.ny.gov

SPDES Permit - WTC Authorization Request Page 1 of 2

For help completing this form refer to instructions page and to http://www.dec.ny.gov/permits/93245.html .

1.a. Date Signed by Permittee - 1.b. Date Signed by WTC Manufacturer -

2.a. Permittee Name - 2.b. SPDES No. - NY

2.c. Contact Name -

3.a. WTC Name -

3.b. WTC Manufacturer -

4.a. WTC Function -

4.b. If WTC is a biocide is it NYS registered? 4.c. Registration Number -

5. WTC Point of Addition -

6. Affected Outfall(s) -

7.a. WTC Daily Dosage: average lbs/day = , maximum lbs/day =

7.b. Dosage Frequency: minutes/day = , days/week =

8.a. Outfall Flow Rate: average MGD = , maximum MGD =

8.b. Outfall WTC Concentration: average mg/l = , maximum mg/l =

9.a. System Blowdown Flow Rate: average gpm = , maximum gpm =

9.b. System Blowdown Frequency: minutes/day = , days/week =

10.a. WTC Composition - Ingredients/Impurities (note: ingredients/impurities must total to 100%)

10.b. % 10.c. CAS# 10.d. Outfall Concentration mg/l mg/l mg/l mg/l mg/l mg/l mg/l

10.e. Intermediate/Final Degradation Products -

11. WTC BOD and COD (lb/lb) -

(July 2023) http://www.dec.ny.gov/permits/93245.html

SPDES Permit - WTC Authorization Request Page 2 of 2 (July 2023)

1.a. Date Signed by Permittee - 1.b. Date Signed by WTC Manufacturer -

2.b. SPDES No. - NY

3.a.. WTC Name - 7.a. Avg/Max Daily Dosage = / lbs/day

12. WTC Toxicity Info (most sensitive species) - Attach description of endpoint for each EC50.

12.a. Vertebrate Species Acute LC50 Acute EC50 Chronic NOEC Chronic IC25 mg/l mg/l mg/l mg/l

12.b. Vertebrate Species Acute LC50 Acute EC50 Chronic NOEC Chronic IC25 mg/l mg/l mg/l mg/l

12.c. Invertebrate Species Acute LC50 Acute EC50 Chronic NOEC Chronic IC25 mg/l mg/l mg/l mg/l

12.d. Invertebrate Species Acute LC50 Acute EC50 Chronic NOEC Chronic IC25 mg/l mg/l mg/l mg/l

13. Summarize measures in place to ensure that excessive levels of WTC are not used -

14. WTCs to be discontinued when use of this WTC begins –

15. Permittee Certification - I certify under penalty of law that this request and all attachments are, to the best of my knowledge and belief, true, accurate and complete. I also certify that the WTC Usage Requirements and any additional requirements specified in the decision letter I will receive will be adhered to.

PRINT NAME - SIGNATURE -

TITLE/COMPANY -

TELEPHONE - EMAIL -

16. WTC Manufacturer Certification - I certify under penalty of law that Sections 1-4, 10-12 and any additional composition documentation submitted with as part of this request are, to the best of my knowledge and belief, true, accurate and complete.

PRINT NAME - SIGNATURE -

TITLE/COMPANY -

TELEPHONE - EMAIL -