1300-PM-BIT0001 5/2012
    Form
     
     
     
    1300-PM-BIT0001 5/2012
     
     
    COMMONWEALTH OF PENNSYLVANIA
    DEPARTMENT OF ENVIRONMENTAL PROTECTION

     
     

    GENERAL INFORMATION FORM – AUTHORIZATION APPLICATION

    Before completing this General Information Form (GIF), read the step-by-step instructions provided in this application package. This version of the General Information Form (GIF) must be completed and returned with any program-specific application being submitted to the Department.
    Related ID#s (If Known)
    DEP USE ONLY
    Client ID#
         
    APS ID#
         
    Date Received & General Notes
    Site ID#
         
    Auth ID#
           
    Facility ID#
               
    CLIENT 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 Suffix SSN
                                 
    Additional Individual Last Name First Name MI Suffix SSN
                                 
    Mailing Address Line 1 Mailing Address Line 2
               
    Address Last Line – City State ZIP+4 Country
                           
    Client Contact Last Name First Name MI Suffix
                           
    Client Contact Title Phone Ext
                    
    Email Address FAX
               
    SITE INFORMATION
    DEP Site ID# Site Name
               
    EPA ID#       Estimated Number of Employees to be Present at Site      
    Description of Site
         
    County Name Municipality
    City
    Boro
    Twp
    State
                   
     
      
    County Name Municipality
    City
    Boro
    Twp
    State
                        
    Site Location Line 1 Site Location Line 2
               
    Site Location Last Line – City State ZIP+4
                  
    Detailed Written Directions to Site
         
    Site Contact Last Name First Name MI Suffix
                           
    Site Contact Title Site Contact Firm
               
    Mailing Address Line 1 Mailing Address Line 2
               
    Mailing Address Last Line – City State ZIP+4
                  
    Phone Ext FAX Email Address
                          
    NAICS Codes (Two- & Three-Digit Codes – List All That Apply) 6-Digit Code (Optional)
               
    Client to Site Relationship
         
    FACILITY INFORMATION
    Modification of Existing Facility
    Yes
    No
    1. Will this project modify an existing facility, system, or activity?
     
     
    2. Will this project involve an addition to an existing facility, system, or activity?    
      If “Yes”, check all relevant facility types and provide DEP facility identification numbers below.
      Facility Type DEP Fac ID#   Facility Type DEP Fac ID#
      Air Emission Plant         Industrial Minerals Mining Operation      
      Beneficial Use (water)         Laboratory Location      
      Blasting Operation         Land Recycling Cleanup Location      
      Captive Hazardous Waste Operation         MineDrainageTrmt/LandRecyProjLocation      
      Coal Ash Beneficial Use Operation         Municipal Waste Operation      
      Coal Mining Operation         Oil & Gas Encroachment Location      
      Coal Pillar Location         Oil & Gas Location      
      Commercial Hazardous Waste Operation         Oil & Gas Water Poll Control Facility      
      Dam Location         Public Water Supply System      
      Deep Mine Safety Operation -Anthracite         Radiation Facility      
      Deep Mine Safety Operation -Bituminous         Residual Waste Operation      
      Deep Mine Safety Operation -Ind Minerals         Storage Tank Location      
      Encroachment Location (water, wetland)         Water Pollution Control Facility      
      Erosion & Sediment Control Facility         Water Resource      
      Explosive Storage Location         Other:            
    Latitude/Longitude
    Latitude
    Longitude
    Point of Origin
    Degrees
    Minutes
    Seconds
    Degrees
    Minutes
    Seconds
                                             
    Horizontal Accuracy Measure Feet       --or-- Meters      
    Horizontal Reference Datum Code   North American Datum of 1927
        North American Datum of 1983
        World Geodetic System of 1984
    Horizontal Collection Method Code      
    Reference Point Code      
    Altitude Feet       --or-- Meters      
    Altitude Datum Name   The National Geodetic Vertical Datum of 1929
        The North American Vertical Datum of 1988 (NAVD88)
    Altitude (Vertical) Location Datum Collection Method Code      
    Geometric Type Code      
    Data Collection Date      
    Source Map Scale Number       Inch(es) =       Feet
    --or--
          Centimeter(s) =       Meters
    PROJECT INFORMATION
    Project Name
         
    Project Description
         
    Project Consultant Last Name First Name MI Suffix
                           
    Project Consultant Title Consulting Firm
               
    Mailing Address Line 1 Mailing Address Line 2
               
    Address Last Line – City State ZIP+4
                     
    Phone Ext FAX Email Address
                          
    Time Schedules Project Milestone (Optional)
               
               
               
               
               
               
    1.
    Have you informed the surrounding community and addressed any concerns prior to submitting the application to the Department?
      Yes   No
    2.
    Is your project funded by state or federal grants?
      Yes   No
      Note: If “Yes”, specify what aspect of the project is related to the grant and provide the grant source, contact person and grant expiration date.
        Aspect of Project Related to Grant
        Grant Source:        
        Grant Contact Person:        
        Grant Expiration Date:        
    3.
    Is this application for an authorization on Appendix A of the Land Use Policy? (For referenced list, see Appendix A of the Land Use Policy attached to GIF instructions)
      Yes   No
      Note:
    If “No” to Question 3, the application is not subject to the Land Use Policy.
        If “Yes” to Question 3, the application is subject to this policy and the Applicant should answer the additional questions in the Land Use Information section.
    LAND USE INFORMATION
    Note: Applicants are encouraged to submit copies of local land use approvals or other evidence of compliance with local comprehensive plans and zoning ordinances.
    1.
    Is there an adopted county or multi-county comprehensive plan?
      Yes   No
    2.
    Is there an adopted municipal or multi-municipal comprehensive plan?
      Yes   No
    3.
    Is there an adopted county-wide zoning ordinance, municipal zoning ordinance or joint municipal zoning ordinance?
      Yes   No
      Note:
    If the Applicant answers “No” to either Questions 1, 2 or 3, the provisions of the PA MPC are not applicable and the Applicant does not need to respond to questions 4 and 5 below.
        If the Applicant answers “Yes” to questions 1, 2 and 3, the Applicant should respond to questions 4 and 5 below.
    4.
    Does the proposed project meet the provisions of the zoning ordinance or does the proposed project have zoning approval? If zoning approval has been received, attach documentation.
      Yes   No
    5.
    Have you attached Municipal and County Land Use Letters for the project?
      Yes   No

    COORDINATION INFORMATION
    Note: The PA Historical and Museum Commission must be notified of proposed projects in accordance with DEP Technical Guidance Document 012-0700-001 and the accompanying Cultural Resource Notice Form.
    If the activity will be a mining project (i.e., mining of coal or industrial minerals, coal refuse disposal and/or the operation of a coal or industrial minerals preparation/processing facility), respond to questions 1.0 through 2.5 below.
    If the activity will not be a mining project, skip questions 1.0 through 2.5 and begin with question 3.0.
    1.0
    Is this a coal mining project? If “Yes”, respond to 1.1-1.6. If “No”, skip to Question 2.0.
      Yes   No
    1.1
    Will this coal mining project involve coal preparation/ processing activities in which the total amount of coal prepared/processed will be equal to or greater than 200 tons/day?
      Yes   No
    1.2
    Will this coal mining project involve coal preparation/ processing activities in which the total amount of coal prepared/processed will be greater than 50,000 tons/year?
      Yes   No
    1.3
    Will this coal mining project involve coal preparation/ processing activities in which thermal coal dryers or pneumatic coal cleaners will be used?
      Yes   No
    1.4
    For this coal mining project, will sewage treatment facilities be constructed and treated waste water discharged to surface waters?
      Yes   No
    1.5
    Will this coal mining project involve the construction of a permanent impoundment meeting one or more of the following criteria: (1) a contributory drainage area exceeding 100 acres; (2) a depth of water measured by the upstream toe of the dam at maximum storage elevation exceeding 15 feet; (3) an impounding capacity at maximum storage elevation exceeding 50 acre-feet?
      Yes   No
    1.6
    Will this coal mining project involve underground coal mining to be conducted within 500 feet of an oil or gas well?
      Yes   No
    2.0
    Is this a non-coal (industrial minerals) mining project? If “Yes”, respond to 2.1-2.6. If “No”, skip to Question 3.0.
      Yes   No
    2.1
    Will this non-coal (industrial minerals) mining project involve the crushing and screening of non-coal minerals other than sand and gravel?
      Yes   No
    2.2
    Will this non-coal (industrial minerals) mining project involve the crushing and/or screening of sand and gravel with the exception of wet sand and gravel operations (screening only) and dry sand and gravel operations with a capacity of less than 150 tons/hour of unconsolidated materials?
      Yes   No
    2.3
    Will this non-coal (industrial minerals) mining project involve the construction, operation and/or modification of a portable non-metallic (i.e., non-coal) minerals processing plant under the authority of the General Permit for Portable Non-metallic Mineral Processing Plants (i.e., BAQ-PGPA/GP-3)?
      Yes   No
    2.4
    For this non-coal (industrial minerals) mining project, will sewage treatment facilities be constructed and treated waste water discharged to surface waters?
      Yes   No
    2.5
    Will this non-coal (industrial minerals) mining project involve the construction of a permanent impoundment meeting one or more of the following criteria: (1) a contributory drainage area exceeding 100 acres; (2) a depth of water measured by the upstream toe of the dam at maximum storage elevation exceeding 15 feet; (3) an impounding capacity at maximum storage elevation exceeding 50 acre-feet?
      Yes   No
    3.0
    Will your project, activity, or authorization have anything to do with a well related to oil or gas production, have construction within 200 feet of, affect an oil or gas well, involve the waste from such a well, or string power lines above an oil or gas well? If “Yes”, respond to 3.1-3.3. If “No”, skip to Question 4.0.
      Yes   No
    3.1
    Does the oil- or gas-related project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a watercourse, floodway or body of water (including wetlands)?
      Yes   No
    3.2
    Will the oil- or gas-related project involve discharge of industrial wastewater or stormwater to a dry swale, surface water, ground water or an existing sanitary sewer system or storm water system? If “Yes”, discuss in Project Description.
      Yes   No
    3.3
    Will the oil- or gas-related project involve the construction and operation of industrial waste treatment facilities?
      Yes   No
    4.0
    Will the project involve a construction activity that results in earth disturbance? If “Yes”, specify the total disturbed acreage.
      Yes   No
      4.0.1 Total Disturbed Acreage      
    5.0
    Does the project involve any of the following?
    If “Yes”, respond to 5.1-5.3. If “No”, skip to Question 6.0.
      Yes   No
    5.1
    Water Obstruction and Encroachment Projects – Does the project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a watercourse, floodway or body of water?
      Yes   No
    5.2
    Wetland Impacts – Does the project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a wetland?
      Yes   No
    5.3
    Floodplain Projec ts by the commonwealth, a Political Subdivision of the commonwealth or a Public Utility – Does the project involve any of the following: placement of fill, excavation within or placement of a structure, located in, along, across or projecting into a floodplain?
      Yes   No
    6.0
    Will the project involve discharge of stormwater or wastewater from an industrial activity to a dry swale, surface water, ground water or an existing sanitary sewer system or separate storm water system?
      Yes   No
    7.0
    Will the project involve the construction and operation of industrial waste treatment facilities?
      Yes   No
    8.0
    Will the project involve construction of sewage treatment facilities, sanitary sewers, or sewage pumping stations? If “Yes”, indicate estimated proposed flow (gal/day). Also, discuss the sanitary sewer pipe sizes and the number of pumping stations/treatment facilities/name of downstream sewage facilities in the Project Description, where applicable.
      Yes   No
      8.0.1 Estimated Proposed Flow (gal/day)      
    9.0
    Will the project involve the subdivision of land, or the generation of 800 gpd or more of sewage on an existing parcel of land or the generation of an additional 400 gpd of sewage on an already-developed parcel, or the generation of 800 gpd or more of industrial wastewater that would be discharged to an existing sanitary sewer system?
      Yes   No
      9.0.1
    Was Act 537 sewage facilities planning submitted and approved by DEP? If “Yes” attach the approval letter. Approval required prior to 105/NPDES approval.
      Yes   No
    10.0
    Is this project for the beneficial use of biosolids for land application within Pennsylvania? If “Yes” indicate how much (i.e. gallons or dry tons per year).
      Yes   No
      10.0.1 Gallons Per Year (residential septage)      
      10.0.2 Dry Tons Per Year (biosolids)      
    11.0
    Does the project involve construction, modification or removal of a dam? If “Yes”, identify the dam.
      Yes   No
      11.0.1 Dam Name      
    12.0
    Will the project interfere with the flow from, or otherwise impact, a dam? If “Yes”, identify the dam.
      Yes   No
      12.0.1 Dam Name      
    13.0
    Will the project involve operations (excluding during the construction period) that produce air emissions (i.e., NOX, VOC, etc.)? If “Yes”, identify each type of emission followed by the amount of that emission.
      Yes   No
      13.0.1
    Enter all types & amounts of emissions; separate each set with semicolons.
         
    14.0
    Does the project include the construction or modification of a drinking water supply to serve 15 or more connections or 25 or more people, at least 60 days out of the year? If “Yes”, check all proposed sub-facilities.
      Yes   No
      14.0.1 Number of Persons Served      
      14.0.2 Number of Employee/Guests      
      14.0.3 Number of Connections      
      14.0.4 Sub-Fac: Distribution System   Yes   No
      14.0.5 Sub-Fac: Water Treatment Plant   Yes   No
      14.0.6 Sub-Fac: Source   Yes   No
      14.0.7 Sub-Fac: Pump Station   Yes   No
      14.0.8 Sub Fac: Transmission Main   Yes   No
      14.0.9 Sub-Fac: Storage Facility   Yes   No
    15.0
    Will your project include infiltration of storm water or waste water to ground water within one-half mile of a public water supply well, spring or infiltration gallery?
      Yes   No
    16.0
    Is your project to be served by an existing public water supply? If “Yes”, indicate name of supplier and attach letter from supplier stating that it will serve the project.
      Yes   No
      16.0.1 Supplier’s Name      
      16.0.2 Letter of Approval from Supplier is Attached   Yes   No
    17.0
    Will this project involve a new or increased drinking water withdrawal from a stream or other water body? If “Yes”, should reference both Water Supply and Watershed Management.
      Yes   No
      17.0.1 Stream Name      
    18.0
    Will the construction or operation of this project involve treatment, storage, reuse, or disposal of waste? If “Yes”, indicate what type (i.e., hazardous, municipal (including infectious & chemotherapeutic), residual) and the amount to be treated, stored, re-used or disposed.
      Yes   No
      18.0.1 Type & Amount      
    19.0
    Will your project in volve the removal of coal, minerals, etc. as part of any earth disturbance activities?
      Yes   No
    20.0
    Does your project involve installation of a field constructed underground storage tank? If “Yes”, list each Substance & its Capacity. Note: Applicant may need a Storage Tank Site Specific Installation Permit.
      Yes   No
      20.0.1
    Enter all substances & capacity of each; separate each set with semicolons.
         
    21.0
    Does your project involve installation of an aboveground storage tank greater than 21,000 gallons capacity at an existing facility? If “Yes”, list each Substance & its Capacity. Note: Applicant may need a Storage Tank Site Specific Installation Permit.
      Yes   No
      21.0.1
    Enter all substances & capacity of each; separate each set with semicolons.
         
    22.0
    Does your project involve installation of a tank greater than 1,100 gallons which will contain a highly hazardous substance as defined in DEP’s Regulated Substances List, 2570-BK-DEP2724? If “Yes”, list each Substance & its Capacity. Note: Applicant may need a Storage Tank Site Specific Installation Permit.
      Yes   No
      22.0.1
    Enter all substances & capacity of each; separate each set with semicolons.
         
    23.0
    Does your project involve installation of a storage tank at a new facility with a total AST capacity greater than 21,000 gallons? If “Yes”, list each Substance & its Capacity. Note: Applicant may need a Storage Tank Site Specific Installation Permit.
      Yes   No
      23.0.1
    Enter all substances & capacity of each; separate each set with semicolons.
         
    24.0
    Will the intended activity involve the use of a radiation source?
      Yes   No
    CERTIFICATION
    I certify that I have the authority to submit this application on behalf of the applicant named herein and that the information provided in this application is true and correct to the best of my knowledge and information.
    Type or Print Name      
                     
    Signature   Title   Date

    Back to top



    Page 1 of 1
     

     

    Page 3 of 3