1300-PM-BIT0001 5/2012
    Form
    Page 1 of 7
    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

    1300-PM-BIT0001 5/2012
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    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

    1300-PM-BIT0001 5/2012
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    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

    1300-PM-BIT0001 5/2012
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    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

    1300-PM-BIT0001 5/2012
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    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 Projects 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

    1300-PM-BIT0001 5/2012
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    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 involve 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.

    1300-PM-BIT0001 5/2012
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    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

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