DWQ-2024-000724

STATE OF UTAH, DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WATER QUALITY195 North 1950 West, P.O. Box 144870, Salt Lake City, Utah 84114-4870(801)536-4300
NOINotice of Intent (NOI) for Coverage Under the UPDES General Permit for Coal Mine Operations No. UTG040000
Submission of this Notice of Intent constitutes notice that the party(s) identified in Section I of this form intends to be authorized by a UPDES permit issued for discharges of alkaline
mine water drainage, storm water runoff from coal preparation plant associated areas, active mining areas, and post mining areas from coal mining operations in the State of Utah.Becoming
a permittee obligates such discharger to comply with the terms and conditions of the permit.ALL NECESSARY INFORMATION MUST BE PROVIDED ON THIS FORM.Has coverage under the Utah Multi-Sector
General Permit for Discharges of Stormwater Associated with Industrial Activity (MSGP) been obtained as required?YN
Is the facility located in Indian Country?YN If yes, do not complete this NOI; instead submit an application for coverage under a storm water permit to EPA Region VIII (EPA form 3510-6).I.OWNER
INFORMATION□Check here if Operator Information is the same as Owner Information
Owner Name:________________________________________________Status of Owner(circle one):Federal Public State Private
Address:______________________________________________________________________________
City:____________________________________________State:______Zip:________________
OWNER POINT OF CONTACT INFORMATION:
First Name:__________________________Last Name: _____________________________Phone:_____________________________
Title: __________________________________________________Email: ____________________________________________________
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OPERATOR INFORMATION(Do not fill out if Operator is same as Owner)
Operator Name: ________________________________________________________________________
Mailing Address:_______________________________________________________________________
City:____________________________________________State:______Zip:________________
OPERATOR POINT OF CONTACT INFORMATION:
First Name:__________________________Last Name: _____________________________Phone:_____________________________
Title: __________________________________________________ Email: ____________________________________________________II.FACILITY SITE/LOCATION INFORMATIONFacility/SiteName:_______________________________________________________________________________
Address:_______________________________________________________County:____________________________
City:___________________________________________________________State:_____Zip:_________________
Latitude: _______________________Longitude: ______________ ______
Specify Coordinate System (circle one): Decimal Degrees or Degrees Minutes SecondsIII.The NOI shall include the location and identification number (such as 001, 002, etc.) of each existing
discharge and/or proposeddischarge point(s). This includes the latitude and longitude and the name of the receiving water(s). The type of wastewater planned to bedischarged (i.e. alkaline
mine water drainage, storm water runoff from coal preparation plant associated areas, active mining areas, and post mining areas) shall also be identified. If additional space is needed,
please attach an additional page with the NOI.Outfall IDOutfallLocation DescriptionLatitudeLongitudeType of WastewaterContinuous (C) or Intermittent (I)Receiving Water(s)
IV. 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 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.Signature: ___________________________________________________________________Date: ______________________________Print
Name: ________________________________________________________________________________________________________Title: _______________________________________________________________________