Facility Name:

Facility Address:

EPA Facility ID:

Facility Latitude/Longitude:

Facility Qualified Individual (Last name, First name):

Facility Contact (phone):

Facility Contact (email):

Parent Company:

Facility industry NAICS code:

1. Does the facility have a maximum quantity onsite of a CWA hazardous substance greater than or equal to the CWA Reportable Quantity (RQ)x 1,000?

Yes__ No__

If Yes, list names, CAS no., and maximum quantities (lbs) onsite for each CWA hazardous substance:

If No, you do not need to proceed.

2. Is the facility within one-half mile of navigable waters or a conveyance to navigable waters?

Yes__ No__

If Yes, list navigable waters and a description of conveyance(s).

If No, you do not need to proceed.

If the answers to both 1 and 2 are Yes, answer questions 3-6.

3. Is the facility located at a distance such that a worst case discharge from the facility could cause injury to fish, wildlife, and sensitive environments? For further description of fish, wildlife, and sensitive environments (FWSE), see the applicable Area Contingency Plan (ACP). Attach documentation of the formulas, assumptions, ACP(s) consulted, and distances calculated.

Yes __ No __

4. Is the facility located at a distance such that a worst case discharge from the facility could cause injury to public receptors? Attach documentation of the formulas and distances calculated.

Yes __ No __

5. Would a worst case discharge from the facility cause substantial harm to a public water system by causing any one, or any combination of more than one, of the adverse impacts listed below?

(i) Violates any National Primary Drinking Water Standard or State Drinking Water Regulation, such as exceedance of a Maximum Contaminant Level;

(ii) Compromises the ability of the public water system to produce water that complies with any National Primary Drinking Water Standard or State Drinking Water Regulation;

(iii) Results in adverse health impacts in people exposed to the maximum concentration that could enter a drinking water distribution system;

(iv) Contaminates public water system infrastructure, including but not limited to intake structures, treatment facilities, and distribution systems, or premise plumbing systems to a degree that requires remediation to restore system components to acceptable performance; or

(v) Impairs the taste, odor, or other aesthetic characteristic of the water entering a drinking water distribution system to a degree that could make the water unacceptable to consumers and that could prompt the public water system to issue use restrictions.

Yes __ No __

Attach documentation of the methodology and assumptions used to evaluate the potential of a worst case discharge to cause each of the adverse impacts (i-v).

For each worst case discharge scenario list:

—CWA hazardous substance name, CAS no. and worst case discharge quantity (lbs) —Worst case discharge scenario type (single container or interconnected containers) —Name(s) of each FWSE receptor(s) and planning distance(s) to FWSE (feet or miles) —Type(s) and description(s) of public receptor(s) and planning distance(s) to public receptor(s) (feet or miles) —Adverse impacts (i-v) to a public water system

Attach documentation attesting to the required consultation with the applicable downstream public water system, including name of public water system, point of contact, and date of consultation for each potentially impacted public water system. If efforts to coordinate with the applicable downstream public water systems were unsuccessful, provide documentation to demonstrate the efforts to coordinate and provide the distance to the first downstream public water system intake.

6. Has the facility experienced a reportable CWA hazardous substance discharge to navigable waters within the last five years?

Yes __ No __

Attach relevant documentation of past reportable discharges.

For each reportable discharge identify:

Name of CWA hazardous substance, CAS no.

Date of discharge:

Duration of discharge (minutes):

Quantity discharged (lbs):

Navigable water(s) reached:

Injury caused to FWSE:

Injury caused to public receptors:

Adverse impacts to public water systems:

NRC report number:

Certification

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 gathered and evaluated 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 have no personal knowledge that the information submitted is other than 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.

Signature Name (please type or print) Title Date Phone/Email