NPDES General Permit 1200-C Renewal Application Instructions
A. Site and Contact Information
NOTE: If the applicant’s legal name has changed or you are no longer the owner/operator of the project, you must submit
Name Change/Permit Transfer Form to DEQ. Forms are available at:
1. Enter the legal name of the applicant. The name must be a legal, active name registered with the Secretary of State
Corporation Division, unless otherwise exempted by their rules:
2. The DEQ File Number can be found o
n your permit cover page or on your Renewal Application Letter.
3. Enter the Project/Common name of the site and the physical location of the project.
4. The Legally Responsible Contact is responsible for receiving official correspondence from DEQ and may be contacted if
there are questions concerning your renewal application.
5. The Facility Contact is the person located at the site that has specific knowledge of the project (e.g., the general
contractor) and may be contacted if there are specific questions.
6. Provide Invoice Contact information for billing of DEQ annual permit fee. This is the person or entity legally
responsible for payment of the annual fee invoice, not a third party independent of the applicant.
B. Required Information
Please include a brief description of any ESCP revisions and submit an ESCP
drawing with your application, if applicable.
C. Signature of Legally Authorized Representative
The signature of the legally authorized representative is required to process this application.
Definition of Legally Authorized Representative
See 40 CFR §122.22 for more detail. Also, please also provide the information requested in brackets [ ]
♦ Corporation — President, secretary, treasurer, vice-president, or any person who performs principal business functions;
a manager of one or more facilities that is authorized in accordance to corporate procedure to sign such documents.
♦ Partnership — General partner [list of general partners, their addresses and telephone numbers]
♦ Sole Proprietorship — Owner
♦ City, County, State, Federal, or other Public Facility — Principal executive officer or ranking elected official
♦ Limited Liability Company — Member [articles of organization]
♦ Trusts — Acting trustee [list of trustees, their addresses and telephone numbers]
Submit Your Application to:
City of Eugene
99 W. 10th Avenue
Eugene, OR 97401
City of Troutdale
342 SW 4th Street
Troutdale, OR 97060
Clean Water Services
2550 SW Hillsboro Highway
Hillsboro, OR 97123
Includes Banks, Beaverton, Cornelius,
Durham, Forest Grove, Gaston, Hillsboro,
King City, North Plains, Sherwood, Tigard,
Tualatin, and portions of Washington Co
DEQ Northwest Region DEQ Western Region DEQ Eastern Region
DEQ Northwest Region
700 NE Multnomah St, Suite 600
Portland, OR 97232-4100
503-229-5886 or 1-800-452-4011
DEQ Western Region
165 East 7th Avenue, Suite 100
Eugene, OR 97401
541-686-7930 or 1-800-844-8467
DEQ Eastern Region
800 SE Emigrant Avenue, Suite 330
Pendleton, OR 97801
541-278-4605 or 1-800-304-3513
Clackamas Benton Lane Baker Hood River Sherman
Clatsop Coos Lincoln Crook Jefferson Umatilla
Columbia Curry Linn Deschutes Klamath Union
Multnomah Douglas Marion Gilliam Lake Wallowa
Tillamook Jackson Polk Grant Malheur Wasco
Washington Josephine Yamhill Harney Marrow Wheeler
Rogue Valley Sewer
138 West Vilas Road,
PO Box 3130
Central Point, OR 97502
Includes Central Point, Phoenix, Talent, White
rtions of Jackson Co.