1. ammonia 2. asbestos (fibrous) 3. cyanide (total) 4. antimony (total) 5. arsenic (total) 6. beryllium (total) 7. cadmium (total) 8. chromium (total) 9. copper (total) 10. lead (total) 11. mercury (total) 12. nickel (total) 13. selenium (total) 14. silver (total) 15. thallium (total) 16. zinc (total) 17. acenaphthene 18. acenaphthylene 19. acrolein 20. acrylonitrile 21. aldrin 22. anthracene 23. benzene 24. benzidine 25. benzo(a) anthracene 26. benzo(a) pyrene 27. benzo(b) fluoranthene 28 benzo(g,h,i) perylene 29. benzo(k) fluoranthene 30. a-BHC (alpha) | 31. b-BHC (beta) 32. d-BHC (delta) 33. g-BHC (gamma) 34. bis (2-chloroethyl)ether 35. bis (2-chloroethoxy) methane 36. bis (2-chloroisopropyl) ether 37. bis (chloromethyl) ether 38. bis (2-ethylhexyl) phthalate 39. bromodi- chloromethane 40. bromoform 41. bromomethane 42. 4-bromo phenylphenyl ether 43. butylbenzyl phthalate 44. cuban tetrachloride 45. chlordane 46. 4-chloro- 3-methylphenol 47. chlorobenzene 48. chloroethane 49. 2-chloro ethylvinyl ether 50. chloroform 51. chloromethane 52. 2-chloro naphthalene | 53. 2-chlorophenol 54. 4-chloro phenylphenyl ether 55. chrysene 56. 4,4'- DDD 57. 4,4'- DDE 58. 4,4'- DDT 59. dibenzo(a,h) anthracene 60. dibromo chloromethane 61. 1, 2-dichloro benzene 62. 1, 3-dichloro benzene 63. 1, 4-dichloro benzene 64. 3, 3'-dichloro benzidine 65. dichloro difluoromethane 66. 1, 1-dichloro ethane 67. 1, 2-dichloro ethane 68. 1, 1-dichloro ethene 69. trans-1, 2-dichloroethene 70. 2, 4-dichloro phenol 71. 1, 2-dichloro propane 72. (cis & trans) 1,3-dichloropropene 73. dieldrin 74. diethyl phthalate 75. 2,4-dimethy1 phenol | 76. dimethyl phthalate 77. di-n-butyl phthalate 78. di-n-octyl phthalate 79. 4, 6-dinitro- 2-methylpheno1 80. 2, 4-dinitrophenol 81. 2, 4-dinitro toluene 82. 2, 6-dinitro toluene 83. 1, 2-diphenyl hydrazine 84. endosulfan I 85. endosulfan II 86. endosulfan sulfate 87. endrin 88. endrin aldehyde 89. ethylhenzene 90. fluoranthene 91. fluorene 92. heptachlor 93. heptachlor epoxide 94. hexachloro benzene 95. hexachloro butadiene 96. hexachloro cyclopentadiene 97. hexachloro ethane 98. indeno(l, 2,3-cd) pyrene 99. isophorone 100. methylene chloride |
Form 4
BASELINE REPORT GENERAL 1. Industry Name 2. Industry Address 3. Owner 4. Contact Person 5. Telephone Number PERMITS 1. List any environmental control permits held by or for the facility: Permit No. Wastewater Water Air Other* *Other - Specify here OPERATIONS 1. Describe the operations at this facility. 2. What is your average rate of production: 3. Provide the Standard Industrial Classification (SIC) for all operations at this facility. If unknown, list the operations only. OPERATIONS SIC 4. Provide a schematic process diagram indicating the points of discharge to the POTW. WASTEWATER FLOW MEASUREMENT 1. Flow from process streams: a. average daily flow: gallons/day b. maximum daily flow: gallons/day 2. Flow from other sources: Source
Average Daily Flow (gal/day) Maximum Daily |
MEASUREMENT OF POLLUTANTS 1. List the regulated processes and applicable Pretreatment Standards: 2. Provide laboratory analysis results identifying the nature and concentration of regulated pollutants in the discharge. Daily maximum and average concentrations are required. Sampling procedures are as follows: a. State the type of sample (i.e. flow proportional, composite, grab). b. For flow less than 250,000 gallons/day, three samples within a two week period must be taken. For flow greater than 250,000 gallons/day, six samples within a two week period must be taken. c. Samples should be taken immediately downstream from pretreatment facilities if such exist or immediately downstream from the process. d. Sampling and analysis must be performed in accordance with techniques prescribed by U.S. EPA. e. The time, date and place of the sampling, methods of analysis and a certification that the sampling and analysis is representative of normal work cycles and expected pollutant discharges must be included. CERTIFICATION Please sign the appropriate certification statement. (1) I hereby certify that the appropriate Pretreatment Standards are being met on a consistent basis. Signature Title Date (2) I hereby certify that the appropriate Pretreatment Standards are not being met on a consistent basis. The requirements to meet these standards are: Signature Title Date COMPLIANCE SCHEDULE If certification (2) was signed, please complete Form 6, attached. |
VILLAGE OF WHITEHOUSE INDUSTRIAL PRETREATMENT PROGRAM COMPLIANCE REPORT 1. Discharger Name Mailing Address Facility Address Telephone 2. Wastewater Characteristics a. List the prohibited or regulated substance contained in the discharge along with the nature and concentration. Substance Nature Concentration b. Wastewater Flow: Average gal/day Maximum gal/day c. Are all applicable Pretreatment Standards being met on a consistent basis? d. If not, what additional operation and maintenance and/or pretreatment is : 3. Sampling and Laboratory Analysis Attach all sampling and laboratory analysis reports for the previous six months, including flow. 4. The information provided in this Compliance Report is familiar to me and to the best of my knowledge and belief, such information is true, complete and accurate. Date Principal Executive Officer Print name here |
Form 6
SCHEDULE OF COMPLIANCE Industry Name: Industry Address: Contact Person: Title: Signature: Date: ACTIVITY COMPLETION 1. Hire engineer 2. Complete preliminary plans 3. Complete final plans 4. Execute contract for major components 5. Commence construction 6. Complete construction NOTES: 1. Progress reports must be submitted within 14 days after each completion date. 2. No increment may exceed nine months. |