Unless stated otherwise, all items are to be filled out completely. If an item is not application, indicate by noting “NA.”
Section I Applicant and Facility Description
1. Name of Facility
2. Mailing Address
3. Address of Premises
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.
Printed Name of Signing Official Title
Signature of Signing Official Date
4. Applicant’s Authorized Agent or Contact Official
Name and Title
Phone
Section II Plant Operations
1. Provide a detailed description of the manufacturing process or service activity provided on the premises (use additional sheets if necessary):
2. Principal raw materials used:
3. Chemicals and compounds used:
4. Description of products or service:
5. If your facility is subject to a National Categorical Pretreatment Standard, has a baseline report (403.12(b)) been submitted? If so, when?
Section III Water Usage and Discharge Information
1. List intake water sources and volumes:
Source Volume
Municipal Water System gallons/day
Private Well gallons/day
Surface Water gallons/day
Other (specify) gallons/day
2. List average volume of discharge or water loss to:
* City Sewer System gallons/day
Natural Outlet gallons/day
Waste Hauler gallons/day
Evaporation gallons/day
Contained in Product gallons/day
Other (specify) gallons/day
3. List average water usage for:
* Process Wastestream #1 gallons/day
* Process Wastestream #2 gallons/day
* Process Wastestream #3 gallons/day
* Cooling Water gallons/day
* Sanitary Water gallons/day
Boiler Feed gallons/day
Other (specify) gallons/day
* These values must be average measured volumes, not approximated.
4. Describe how each process wastestream is generated:
5. Is the discharge to the sewer: Continuous Batch
If batch discharge give the frequency of occurrence
What is the average volume in gallons of each batch
6. Provide a schematic of the plant flow showing process, sanitary, cooling streams, etc., and their point of entry into the sewer system. Indicate on the schematic, the point where sampling will occur.
Section IV Pretreatment
1. Describe any wastewater treatment equipment of processes in use:
2. Describe any additional pretreatment facilities and/or processes under consideration. Include a specific time for completion:
3. If a pretreatment system exists, what method is utilized to dispose to pretreatment sludges/residuals?
Section V Wastewater Characteristics
1. Attach any sampling data pertaining to the facility discharge to the sewer system. Explain where and when the sampling was accomplished, what type of sample was taken (i.e., grab, composite), and how many were analyzed.
2. If no sampling data is available, testing must be performed on the discharge for any pollutant believed to be present. The sample must be a 24-hour composite taken during normal production activity and/or representing typical wastewater flows. A representative list of pollutants is contained in Table I attached to this application. Please check the pollutants you know or suspect of being in your discharge.
Section VI Mailing Address
Send completed application with attachments and enclosures to:
TABLE I
PRIORITY POLLUTANTS
I. METALS AND INORGANICS
Antimony; Sb
Arsenic; As
Asbestos
Beryllium; Be
Cadmium; Cd
Chromium; Cr
Copper; Cu
Cyanides; CN
Lead; Pb
Mercury; Hb
Nickel; Ni
Selenium; Se
Silver; Ag
Thallium; Tl
Zinc; Zn
II. TOXIC ORGANICS: ETHERS
Ether, bis(2-chloroethyl)
Ether, bis(2-chloroisopropyl)
Ether, 2-chloroethyl vinyl
Ether, 4-chlorophenyl phenyl
Ether, 4-bromophenyl phenyl
Bis (2-chloroethoxy) methane
III. TOXIC ORGANICS: PHTHALATES
Phthalate, dimethyl; DMP
Phthalate, diethyl; DEP
Phthalate, di-n-butyl; DBP
Phthalate, di-n-octyl; DOP
Phthalate, bis(2-ethylhexyl); DEHP
Phthalate, butyl benzyl; BBP
IV. TOXIC ORGANICS; NITROGEN COMPOUNDS
Nitrosamine, dimethyl
Nitrosamine, diphenyl
Nitrosamine, di-n-propyl
Benzidine
Benzidine, 3,3'-dichloro
Hydrazine, 1,2-diphenyl
Acrylonitrile
V. TOXIC ORGANICS: PHENOLS
Phenol
Phenol, 2-chloro
Phenol, 2,4-dichloro; 2,4-DCP
Phenol, 2,4,6-trichloro
Phenol, pentachloro; PCP
Phenol, 2-nitro
Phenol, 4-nitro
Phenol, 2,4-dinitro; 2,4-DNP
Phenol, 2,4-dimethyl
m-Cresol, p-chloro
o-Cresol, 4,6-dinitro; DNOC
VI. TOXIC ORGANICS; AROMATICS
Benzene
Benzene, chloro
Benzene, 1,2-dichloro
Benzene, 1,3-dichloro
Benzene, 1,4-dichloro
Benzene, 1,2,4-trichloro
Benzene, hexachloro; HCB
Benzene, ethyl
Benzene, nitro
Toluene
Toluene, 2,4-dinitro; DNT
Toluene, 2,6-dinitro
VII. TOXIC ORGANICS:
POLYNUCLEAR AROMATIC
HYDROCARBONS
2-Chloronaphthalene
Benzo (a) anthracene
Benzo (b) fluoranthene; B(b)F
Benzo (k) fluoranthene; B(k)F
Benzo (a) pyrene; BaP
Ideno (1,2,3-cd) pyrene; IP
Dibenzo (a,h) anthracene; DBA
Benzo (ghi) perylene
Acenaphthene
Acenaphthylene
Anthracene
Chrysene
Fluoranthene
Fluorene
Naphthalene
Phenanthrene
Pyrene
VIII. TOXIC ORGANICS: PCB’S
PCB-1016; Aroclor 1016
PCB-1221; Aroclor 1221
PCB-1232; Aroclor 1232
PCB-1242; Aroclor 1242
PCB-1248; Aroclor 1248
PCB-1254; Aroclor 1254
PCB-1260; Aroclor 1260
IX. TOXIC ORGANICS: HALOGENATED HYDROCARBONS; HALOGENATED ALIPHATICS
Methane, chloro; Methyl chloride
Methane, dichloro; Methylene chloride
Methane, trichloro; Chloroform
Methane, tetrachloro; Carbon tetrachloride
Ethane, chloro
Ethane, 1,1-dichloro
Ethane, 1,2-dichloro
Ethane, 1,1,1-trichloro
Ethane, 1,1,2-trichloro
Ethane, 1,1,2,2-tetrachloro
Ethane, hexachloro
Ethane, chloro; Vinyl chloride
Propane, 1,2-dichloro
Propane, 1,3-dichloro
Butadiene,hexachloro; HCBD
Cyclopentadiene, hexachloro; HCCPD
Methane, bromo; Methyl bromide
Methane, dichlorobromo
Methane, chlorodibromo
Methane, tribromo; Bromoform
Ethene, trichloro
Ethene, 1,1-dichloro; 1,1-DCE
Ethene, 1,2-trans-dichloro
Ethene, tetrachloro
X. TOXIC ORGANICS: PESTICIDES
alpha-Endosulfan
Endosulfan sulfate
beta-Endosulfan
Hexachlorocyclohexanes:
alpha-BHC
beta-BHC
delta-BHC
gamma-BHC; Lindane
Aldrin; HHDN
Dieldrin; HEOD
4,4'-DDE
4,4'-DDT; p,p’-DDT
4,4'-DDD; p,p’-DDD; p,p’-TDE
Endrin
Endrin aldehyde
Heptachlor
Heptachlor epoxide
Chlordane
Toxaphene
XI. TOXIC ORGANICS; OXYGENATED COMPOUNDS
Acrolein
XII. TOXIC ORGANICS;
MISCELLANEOUS
Isophorone
2,3,7,8-tetrachlorodibenzo-p-dioxin; TCDD; dioxin
CONVENTIONAL POLLUTANTS
BOD5
pH
Total Suspended Solids (TSS)
Oil and Grease (O&G)
NONCONVENTIONAL POLLUTANTS OF CONCERN
Ammonia (NH3)
Chlorides (CI-)
Sulfides (S-2)
Total Dissolved Solids (TDS)
Phosphates
Chemical Oxygen Demand (COD)