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Get OH EPA 4233 2007-2024

State of Ohio Environmental Protection Agency Ohio NPDES Permit Modification Form Revised 01/07 National Pollutant Discharge Elimination System Application for Modification of Ohio NPDES Permit Note The Ohio EPA Antidegradation Addendum must be submitted with all Applications for Modification. Submit this application to the appropriate district office District Offices Northeast District 2110 East Aurora Road Twinsburg Ohio 44087 Central District P. O. Box 1049 Columbus Ohio 43216-1049 Southwest District 401 East 5th Street Dayton Ohio 45402 Division of Surface Water 50 West Town Street Suite 700 P. O. Box 1049 Columbus Ohio 43216-1049 For Agency Use Facility Name Date Received yy/mm/dd Ohio EPA Permit Number Application Number Permits and Compliance Section A. Permit number for which modification is being requested B. Name of organization responsible for facility C. Address location and telephone number of facility producing the permitted discharge 1. Name 2. Mailing Address Street City State Zip 3. Location Street County 4. Telephone area code no. D. Describe in detail the provision s of the permit the applicant wishes to modify. Attach additional pages as necessary See Ohio Administrative Code 3745-33-04 D for grounds for modification* EPA 4233 01/07 Page 1 of 2 Click to clear all entered information on both pages of this form CLEAR F* Name of receiving water or waters G* Describe requested modification in sufficient detail to allow Ohio Environmental Protection Agency to process your request. If a Permit to Install is required under regulation OAC 3745-42 attach a completed application for a Permit to Install and make no other entries in this section* If a Permit to Install is not required and additional space is needed provide the additional information on attached sheets. Certification I certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief such information is true complete and accurate. O. Box 1049 Columbus Ohio 43216-1049 Southwest District 401 East 5th Street Dayton Ohio 45402 Division of Surface Water 50 West Town Street Suite 700 P. O. Box 1049 Columbus Ohio 43216-1049 For Agency Use Facility Name Date Received yy/mm/dd Ohio EPA Permit Number Application Number Permits and Compliance Section A. O. Box 1049 Columbus Ohio 43216-1049 For Agency Use Facility Name Date Received yy/mm/dd Ohio EPA Permit Number Application Number Permits and Compliance Section A. Permit number for which modification is being requested B. Name of organization responsible for facility C. Permit number for which modification is being requested B. Name of organization responsible for facility C. Address location and telephone number of facility producing the permitted discharge 1. Name 2. Mailing Address Street City State Zip 3. Address location and telephone number of facility producing the permitted discharge 1. Name 2. Mailing Address Street City State Zip 3. Location Street County 4. Telephone area code no. D. Describe in detail the provision s of the permit the applicant wishes to modify.

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