application for a wastewater discharge permit to … discharge application.pdf1. dairy products 3....

February 25 2015

APPLICATION FOR A WASTEWATER DISCHARGE PERMIT TO THE PUBLIC SEWER SYSTEM / BASELINE MONITORING REPORT

SECTION A

General Information

1. Company nameCompany AddressCity State Zip code Telephone numberMailing Address if the same as above check box AddressCity State Zip code Telephone number

2. Check appropriate item: Owner Lease Tenant

Other (Explain)

3. Name of authorized representative for discharge permit:Name Title Telephone number Mobile number E-mail address:

4. Alternate person to contact concerning facility operations and / or information provided herein:Name TitleTelephone number Mobile numberE-mail address:

5. Type of business conducted (auto repair, machine shop, meat packing, processing,electroplating, warehouse, painting, printing, food processing, etc.):

6. Brief narrative description of the manufacturing, production, or service activities your facilityconducts:

7. Standard Industrial classification number(s) (SIC Code) for your facility / facilities( https://www.osha.gov/pls/imis/sicsearch.html )

SIC SIC SIC

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8. This facility generates the following types of wastes: (check all that apply) Average gallons per day

A. Domestic wastes (restrooms employee showers, etc.) estimated measured

B. Boiler/Tower blowdown estimated measured

C. Cooling water, non-contact estimated measured

D. Cooling water, contact estimated measured

E. Process estimated measured

F. Equipment/Facility Wash-down estimated measured

G. Air Pollution Control Unit estimated measured

H. Storm Water estimated measured

I. Other (Describe) estimated measured

9. Waste are discharged to (check all that apply) Average gallons per day

A. Sanitary sewer estimated measured

B. Storm sewer estimated measured

C. Waste Haulers estimated measured

D. Other ( describe ) estimated measured

10. Name and address of waste haulers if used:

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11. Is Spill Prevention Control and Countermeasure (SPCC) plan prepared for the facility? Yes No

If yes, name of person to contact Title Telephone number

Note: If your facility did not check one or more of the items listed in 8.B through 8.I above, sign the last page of this application and return this form to the address listed on page 8. If any items were checked in section 8.B through 8.I complete the remainder of this application prior to submitting this application to the address listed on page 8.

SECTION B

Facility Operation characteristics

1. Number of employee shifts worked per 24-hour day

2. Starting time of each shift: 1st 2nd 3rd

3. Principal product produced:

4. Raw materials and process additives used:

5. Production process is: Batch % Batch Continuous % Continuous Both

6. Hours of operation am to pm Continuous

7. Is production subject to seasonal variation? Yes No

If yes, briefly describe seasonal production cycle:

8. Are any process changes or expansions planned for the next three years? Yes No

If yes, attach a separate sheet to this form describing the nature of planned changes orexpansions.

9. Do you or will you have heavy equipment on your property (forklifts, cranes, trucks,Tractors, etc.) Yes No

If yes, do you service or clean the equipment on your property? Yes NoWhat provisions are made for disposal of old oil, steam cleaning waste, or other wastes?

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10. Do you, or will you use or store industrial chemicals at your business location (oils, fuels,hydraulic fluids, solvents, bulk pesticides, absorbents, surfactants, acids, caustics, etc.)

Yes NoIf yes, list the chemicals used (attach an extra sheet if necessary)

How are wastes of these chemicals discarded? A. Discharged to sanitary sewer systemB. Contained on propertyC. Hauled away (if so specify hauler and ultimate disposal site)

D. Other (explain)

SECTION C

WASTEWATER INFORMATION

1. If your facility employs processes in any of the industrial categories or business activities listed below and any of these process generate wastewater or waste sludges, place a check beside the category or business activity. Check all that apply:

A. Industrial Categories 1. Adhesives 11 Foundries 2. Aluminum forming 12. Gum and wood chemicals3. Auto and other laundries 13. Inorganic chemicals4. Battery manufacturing 14. Iron and steel5. Coal mining 15. Leather tanning/and finishing6. Coiling forming 16. Mechanical products7. Copper forming 17. Non-ferrous metals8. Electric and electronic / components 18. Ore mining9. Electroplating 19. Organic chemicals10. Explosives manufacturing 20. Paint and ink

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21. Pesticides 28. Printing and publishing22. Petroleum and refining 29. Pulp and paper23. Pharmaceuticals 30. Rubber24. Photographic supplies 31. Soaps and detergents25. Plastic and synthetic / materials 32. Steam electric26. Plastics processing 33. Textile mills27. Porcelain enamel 34. Timber

B. Other Business Activities1. Dairy products 3. Food edible products processors2. Slaughter, meatpacking, rendering 4. Beverage bottler

2. Does / will your facility store, use, or discharge to the public sewer system any known priority toxic pollutants as defined under 40-CFR-433.11 Special Definitions (e) and Federal Clean Water Act ? If yes, or you’re uncertain, complete the attached Priority Pollutant Information pages at the end of this application.

3. Indicate your pretreatment devices or processes used for treating wastewater or sludge. Check all that apply:

1. Air flotation 16. Sedimentation2. Centrifuge 17. Septic tank3. Chemical precipitation 18. Solvent separation4. Chlorination 19. Spill protection5. Cyclone 20. Sump6. Filtration 21. Biological treatment7. Flow equalization type 8. Grease or oil separation 22. Rainwater diversion or storage9. Grease trap 23. Other chemical treatment

10. Grit removal type 11. Ion exchange 24. Other physical treatment12. Neutralization, pH correction 25. Other13. Ozonation type 14. Reverse osmosis 26. No pretreatment provided15. Screen

4. Design capacity of treatment system

5. Under what circumstances system would be bypassed?

6. If any wastewater analyses have been performed on the wastewater discharge(s) from yourfacility, attach a copy of the most recent data to this application. Be sure to include the date of theanalysis, name of laboratory performing the analysis, and location(s) from which sample weretaken. Attach sketches, plans, etc. as necessary

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SECTION D

OTHER WASTE

1. Are any liquid waste or sludges from this facility disposed of by means other than discharge tothe sewer system?

If yes complete item # 2 and # 3 of this section. If no skip remainder of Section

Estimated gallons or pounds per year 2. These waste may best be described as:

Acids and Alkalizes

Heavy Metal sludges

Dyes

Oil and /or Grease

Organic compounds

Paints

Pesticides

Plating

Process sludges

Solvents / Thinners

Other hazardous waste (specify)

Other waste (specify)

3. For the above checked waste, does your companypractice: On-site storage Off-site storage On-site disposal Off-site disposal

Briefly describe the method (s) of storage or disposal checked above:

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SECTION E

WATER USE

1. Identify your water intake source and estimate your intake volume in gallons per day

A. Public water supply GPD

Supplier G

Account number (from bill ) G

B. Private water supply GPD

C. Well water GPD

D. Other sources GPD

2. Of the total volume listed: what percentage do you estimate is or will be discharged directlyto the:

A. Storm drain %

B. Sanitary sewer %

C. Other ( identify ) %

3. Water used for:

A Sanitary GPD

B. Air conditioning GPD

C. Process water GPD

D. Jacketed cooling water GPD

E. Direct contact cooling water GPD

F. Other GPD

Period of maximum water use: G

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I understand, that in consideration of the granting of an Industrial Discharge Permit, the undersigned recognizes and agrees:

(1) to cooperate at all times in the inspection, sampling, and study of the industrialwastes;

(2) to accept and abide by all provisions of the Central Valley Pretreatment Ordinance.

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 those persons or people who manage the system, or those people directly responsible for gathering 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 fines and penalties.

(Corporate Official or Operating Manager in Charge) Date

Following the review and acceptance of your application for a discharge permit, the discharge permit will be issued through Central Valley Water Reclamation Facility.

Note: Application may be mailed to or hand delivered to:

Central Valley Water Reclamation Facility 800 West Central Valley Road

Salt Lake City, UT 84119-3379

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TABLE 2 PRIORITY POLLUTANT INFORMATION

For each compound listed below, place a check mark in the space which most appropriately characterizes the compounds use and discharge potential from this facility.

Chemical Compound Used Discharged Discharged Yes No Yes No Intermittently Continuously

METALS AND INORGANICS

1. Antimony

2. Arsenic

3. Asbestos

4. Beryllium

5. Cadmium

6. Chromium

7. Copper

8. Cyanide

9. Lead

10. Mercury

11. Nickel

12. Selenium

13. Silver

14. Thallium

15. Zinc

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PRIORITY POLLUTANT INFORMATION (cont’d)

Chemical Compound Used Discharged Discharged

Yes No Yes No Intermittently Continuously

PHENOLS AND CRESOLS

16. Phenol(s)

17. Phenol, 2-chloro

18. Phenol, 2, 4-dichloro

19. Phenol, 2,4,6-trichloro

20. Phenol, pentachloro

21. Phenol, 2-nitro

22. Phenol, 4-nitro

23. Phenol, 2,4-dinitro

24. Phenol, 2,4-dimethyl

25. m-Cresol, p-chloro

26. o-Cresol, 4,6-dinitroMONOCYLIC AROMATICS (Excluding

Phenols, Cresols, and Phthalates)

27. Benzene

28. Benzene, chloro

29. Benzene, 1, 2-dichloro

30. Benzene 1, 3-dichloro

31. Benzene, 1, 4-dichloro

32. Benzene, 1, 2, 4-trichloro

33. Benzene, hexachloro

34. Benzene, ethyl

35. Benzene, nitro

36. Toluene

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Yes No Yes No Intermittently Continuously

37. Toluene, 2, 4-dinitro

38. Toluene, 2, 6-dinitro

PCB=S AND RELATED COMPOUNDS

39. PCB-1016

40. PCB-1221

41. PCB-1232

42. PCB-1242

43. PCB-1248

44. PCB-1254

45. PCB-1260

46. 2-Chloronaphthalene

ETHERS

47. Ether, bis (chloromethyl)

48. Ether, bis (2-chloroethyl)

49. Ether, bis (2-chlorolsopropyl)

50. Ether, 2-chloroethyl vinyl

51. Ether, 4-bromophenyl phenyl

52. Ether, 4-chlorophenyl phenyl

53. Bis (2-chloroethoxy) methane

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Yes No Yes No Intermittently Continuously NITROSAMINE AND OTHER NITROGEN

CONTAINING COMPOUNDS

54. Nitrosamine, dimethyl

55. Nitrosamine, diphenyl

56. Nitrosamine, di-n-propyl

57. Benzidine

58. Benzidine, 3, 31-dichloro

59. Hydrazine, 1, 2-diphenyl

60. Acrylonitrile

HALOGENATED ALIPHATICS

61. Methane, bromo

62. Methane, chloro

63. Methane, dichloro

64. Methane, chlorodibromo

65. Methane, dichlorobromo

66. Methane, tribromo

67. Methane, trichloro

68. Methane, tetrachloro

69. Methane, trichlorofluoro

70. Methane, dichlorodifluoro

71. Ethane, 1, 1-dichloro

72. Ethane, 1, 2-dichloro

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PRIORITY POLLUTANT INFORMATION ( cont’d)


HALOGENATED ALIPHATICS

73. Ethane, 1, 1, 1-trichloro

74. Ethane, 1, 1, 2-trichloro

75. Ethane 1, 1, 2, 1-tetrachloro

76. Ethane, hexachloro

77. Ethene, chloro

78. Ethene, 1, 1-dichloro

79. Ethene, trans-dichloro

80. Ethene, trichloro

81. Ethene, tetrachloro

82. Propane, 1, 2-dichloro

83. Propane, 2, 4-dichloro

84. Butadiene, hexachloro

85. Cyclopentadiene, hexachloroPHTHALATE ESTERS

86. Phthalate, di-c-methyl

87. Phthalate, di-n-ethyl

88. Phthalate, di-n-butyl

89. Phthalate, di-n-octyl

90. Phthalate, bis (2-ethylhexyl)

91. Phthalate, butyl benzyl

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POLICYCLIC AROMATIC HYDROCARBONS

92. Acenaphthene

93. Acenaphthylene

94. Anthrancene

95. Benzo (a) anthracene

96. Benzo (b) fluoranthene

97. Benzo (k) fluoranthene

98. Benzo (ghl) perylene

99. Benzo (a) pyrene

100. Chrysene

101. Dibenzo (a, n) anthracene

102. Fluoranthene

103. Fluorene

104. Indeno (1, 2, 3-cd) pyrene

105. Naphthalene

106. Phenanthrene

107. Pyrene

PESTICIDES

108. Acrolein

109. Aldrin

110. BHC (alpha)

111. BHC (beta

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PESTICIDES

112. BHC (gamma) or Lindane

113. BHC (delta)

114. Chlordane

115. DDD

116. DDE

117. DDT

118. Dieldrin

119. Endosulfan (alpha)

120. Endosulfan (beta)

121. Endosulfan sulfate

122. Endrin

123. Endrin aldehyde

124. Heptachlor

125. Heptachlor epoxide

126. Isophorone

127. TCDD or Dioxin

128. Toxaphene

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application for a wastewater discharge permit to … discharge application.pdf1. dairy products 3....

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