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Municipal Streamlined Mercury Variance (SMV) Application 52112 - Indiana

Municipal Streamlined Mercury Variance (SMV) Application Form. This is a Indiana form and can be used in Water Department Of Enviromental Management Statewide .
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MUNICIPAL STREAMLINED MERCURY VARIANCE (SMV) APPLICATION State Form 52112 (5-05) Approved by State Board of Accounts, 2005 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Indiana Department of Environmental Management Office of Water Quality ­ Mail Code 65-42 NPDES Permits Branch 100 North Senate Avenue Indianapolis, Indiana 46204-2251 PART ONE: General Information Name of Facility Facility Address City or Town State ZIP Code County National Pollutant Discharge Elimination System (NPDES) Permit No.: Owner or Person in Responsible Charge (i.e., Town Board President/Mayor) Title Address City or Town State ZIP Code Name of Primary Contact Person Address City or Town State E-mail Address (if available) ZIP code Telephone No. NPDES Outfall(s) Affected by Streamlined Mercury Variance Request: Receiving Stream(s) Affected by Streamlined Mercury Variance Request: Facility Design Flow: Population Served: Number of Significant Industrial Users (as defined in 327 IAC 5-17-23): SIGNATURE BLOCK This application must be signed by a person in responsible charge (see 327 IAC 5-2-22) to be valid. This signature attests to the following: 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. Printed Name Signature Title Date Signed (month, day, year) Return the completed SMV application package (Parts I - V) and $50 application fee (see IC 13-18-20-12(a)(4)) to the mailing address listed above. American LegalNet, Inc. www.FormsWorkflow.com PART TWO ­ POLLUTANT MINIMIZATION PROGRAM PLAN (PMPP) INVENTORY/IDENTIFICATION A. Provide a preliminary inventory of potential uses and sources of mercury in all buildings and departments, as well as a preliminary identification of known mercury-bearing equipment, wastestreams, and mercury storage sites. The following checklist* includes many of the chemicals, equipment, locations, etc. where mercury may be present at your site. For the purpose of satisfying the requirements of this section, you may submit the completed checklist as a preliminary inventory/identification. While the checklist is intended to facilitate the inventory/identification process, it should not be considered as all-inclusive for purposes of establishing a complete inventory. (see 327 IAC 5-3.5-9(a)(1) and 327 IAC 5-3.5-9(a)(2)) LABORATORY EQUIPMENT Manometers Ion exchange cartridges for lab water purification system Barometers Hanging mercury drop electrodes for polarographic analyzers Thermometers Mercury Hallow Cathode lamp for AA analysis LABORATORY CHEMICALS COD analysis reagent (mercuric sulfate) Mercury or mercurous chloride TKN and TP analysis digestion reagents Mercury iodide Nessler reagent Mercury nitrate Mercury analytical standards Mercury (II) oxide Gas chromatograph sample interferences (elemental mercury) Mercury (II) sulfate Sodium hypochlorite (Clorox) Merthiolate BULK CHEMICALS Phosphorus removal chemicals Chlorine Dechlorination chemicals Sodium hypochlorite Sludge thickening polymers Sulfuric acid Potassium hydroxide Nitric acid Sodium hydroxide Ferric or ferrous chloride Sodium chloride Pickling liquor (for phosphorus removal) PROCESS CONTROL AND MEASURING EQUIPMENT Accustats Ring balances Barometers Shunt trips Counterweights Steam flow meters Stokes gauges Elemental mercury for refilling mercury-containing equipment Switches and relays: Flow meters Gas regulators and meters Gyroscopes Hydrometers with thermometers Level and rotation sensors Manometers, pressure gauges and vacuum gauges Mercury-sealed pistons Permeters Pressure-trols Pyrometers Rectifiers BUILDINGS DC watt-hour meters Flame sensors (found in the pilot light and burner assembly on gas-fired furnaces, boilers, unit heaters and space heaters) * This checklist was borrowed from the Delta Institute. Displacement plunger relays Mercoid control switches Pressure control switches (mounted on bourdon tube or diaphragm) Relay switches Mercury wetted relays Mercury displacement relays (found in motors) Sump pump, bilge pump and other float controls Tilt switches Thermometers (including industrial dial face thermostats with capillary tubes.) Thermostats and thermoregulators Transmitters Hydronic and warm air controls with tilt switches such as: Aquastats Pressurestats Firestats Fan limit controls Pressure/flow controls on air handling units. 2 American LegalNet, Inc. www.FormsWorkflow.com Municipal Streamlined Mercury Variance Application State Form 52112 (5-05) PART TWO (CONTINUED) BUILDINGS (continued) Switches and relays: Fire alarm box switches Silent light switches Relay switches Mercury wetted relays Phosphorus removal chemicals: Ferric or ferrous chloride Pickling liquor Thermostats BEARINGS AND SEALS Trickling filter Pivot Arm Bearings (mercury bearings/water seals) LAMPS Fluorescent Mercury vapor lamps High-pressure sodium Metal halide Mercury arc Ultraviolet disinfection BATTERIES Mercury-zinc (button) batteries Mercury alkaline batteries Mercury-cadmium batteries Mercury oxide batteries PAINT Old latex-paint (pre-1990) Marine paint FIRST AID/MEDICAL Mercurochrome Thermometers Thimerosal (contained in eye wash) Sphygmomanometers OTHER Fleet vehicles may contain ABS, convenience and trunk lighting Old pesticides, fungicides and herbicides switches and HID headlamps Tree root growth control products Computer monitors COLLECTION SYSTEM Lift station equipment Sewer lines with accumulated mercury Traps with accumulated mercury Other mercury containing equipment Sumps with accumulated mercury Mercury-containing chemicals used and/or stored on-site MERCURY STORAGE SITES Elemental mercury Mercury-containing items collected for disposal B. Provide a plan and schedule for providing a complete inventory initiated under Section A. above. (see 327 IAC 5-3.5-9(a)(1)) The schedule required under this part should be expressed in terms of months from the date of NPDES permit issuance, renewal, or modification that incorporates the approved SM
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