CITY
OF
INDUSTRIAL
USER PERMIT APPLICATION
1. Facility
Name:
a. Operators Name:
b. Is the Operator identified in 1a. the owner
of the facility?
(
) Yes (
) No
If no, provide the name and address of the
owner.
Name:
Address:
2. Facility
Address:
Street:
City: State: Zip:
3. Business
Mailing Address:
Street:
City: State: Zip:
4. Designated Signatory Authority of the
facility:
(Attach similar
information for each authorized representative):
Name:
Title:
Address:
City: State: Zip:
Phone: Fax:
5. Designated Facility Contact:
Name:
Title:
Phone: Fax:
1. If your facility employs or will be
employing processes in any of the industrial
categories or business
activities listed below (regardless of
whether they generate
wastewater, waste
sludge, or hazardous wastes), place a check beside the category
of business activity
(check all that apply).
Industrial Categories *
(
) Aluminum Forming
(
) Asbestos Manufacturing
(
)
(
) Can Making
( )
Carbon Black
(
) Coal Mining
(
) Coil Coating
(
) Copper Forming
(
) Dairy Products Processor
(
) Electric and Electronic
Components Manufacturing
(
) Electroplating
(
) Etching (Ferrous and
Non-ferrous Materials)
(
) Feedlots
(
) Fertilizer manufacturing
(
) Foundries (Metal Molding and
Casting)
(
) Funeral Home
(
) Glass Manufacturing
(
) Grain Mills
(
) Hospital
(
) Inorganic and/or Organic
Chemicals
(
) Iron and Steel
( )
Laundry
( )
Leather Tanning and Finishing
( )
Metal Finishing
( )
Non-ferrous Metals forming and/or Manufacturing
( )
Paint and/or Ink Formulating
( )
Paving and Roofing Manufacturing
( )
Pesticide Manufacturing
( )
Petroleum Refining
( )
Pharmaceutical Manufacturing
( )
Photographic Processing
( )
Plastic and Synthetic Materials Manufacturing
( )
Plastics Processing Manufacturing
( )
Porcelain Enamel
( )
Pulp, Paper, and fiberboard Manufacturing
( )
Rubber
Industrial
Categories (continued)
( ) Soap
and Detergent Manufacturing
( )
Steam Electric
( )
Sugar Processing
( )
Textile Mills
( )
Timber Products
* A
facility with the processes included in these business areas may be covered by
Environmental Protection Agency’s (EPA) “Categorical Pretreatment Standards.
2. Give a brief description of all
operations at this facility including primary products or services (attach
additional sheets as necessary):
3. Indicate applicable Standard Industrial
Classification (SIC) for all processes (if more than one applies list in
descending order of importance):
a.
b.
c.
d.
e.
4. Product Volume:
Product Past Calendar Year Estimate This Year
(Brand Name) (Amounts Per Day) (Amounts Per Day)
(Daily Units)
(Daily Units)
average maximum average maximum
1. Water Sources: (Check all that apply)
( )
Private well
( )
Surface water
( )
Municipal (Specify City):
( )
Other (Specify):
2. Water
billed to:
Name:
Street:
City: State: Zip:
3. Water
Service Account Number:
4. List
average water usage:
Type Av. Consumption Estimate or Actual
(gallons per day) (E) (A)
a. Contact
Cooling Water
b. Non-Contact
Cooling Water
c. Boiler
Feed
d. Process
e. Sanitary
f. Air
Pollution Control
g. Contained
in Product
h. Plant
& Equipment Washdown
i. Irrigation
& Lawns
j. Other:
TOTALS:
1. a. Existing Business:
Is
the facility presently connected to the public sewer?
( ) Yes: Sewer Account Number:
( ) No:
Sewer
Information (continued)
Have
you applied for a sanitary sewer connection? ( ) Yes (
) No
b. New Business:
Will
the business be occupying an existing vacant building? ( )
Yes ( ) No
Have
you applied for a building permit for a new facility? (
) Yes ( ) No
Will
the facility be connected to the public sewer system? (
) Yes ( ) No
2. List size, location, and average flow of each facility sewer connection to the public sewer (outfall).
Sewer
size Location Average
Flow
(gallons
per day)
1. Does (or will) this facility discharge
any wastewater other sanitary to the public sewer?
( ) Yes If yes, complete the remainder of
this form.
( ) No If no, skip to SECTION I.
2. If
continuous discharge, provide the following information (or estimate).
a. Total Hours/Day of discharge:
M_____ T_____
W_____ Th_____ F_____
Sat_____ Sun_____
b.
Hours of Discharge (e.g. 9 A.M. to
5 P.M.:
M_____ T_____
W_____ Th_____ F_____
Sat_____ Sun_____
c. Peak Hourly Flowrate:
d. Maximum Daily Flowrate:
e. Average Daily Flowrate:
Wastewater
Discharge Information (continued)
3. If
batch discharge, provide the following information (or estimate).
a. Days of discharge:
M_____ T_____
W_____ Th______ F_____
Sat_____ Sun_____
b. Hours of discharge (e.g. 9 A.M. to 5
P.M.):
M_____ T_____
W_____ Th_____ F_____
Sat_____ Sun_____
c. Number of Discharges Per Day:
d. Average Gallons Per Discharge:
e. Discharge Flowrate:
f. Percent of Total Facility Discharge:
4. Schematic
Flow Diagram:
a. For each activity in which process
wastewater is or will be generated, provide a diagram of the flow of the
material, products, waster and wastewater from the start of the activity to
completion. Show all unit
processes. Indicate use of estimation
regarding flow information.
b. Indicate which processes use water and
which generate wastestreams.
c. Number
each unit process generating wastewater discharged to the public
sewer. Use these numbers in subsequent sections of
this form.
5. Provide the wastewater discharge flows for each process (or proposed process).
Include the reference number from
the process schematic that corresponds to each process.
No. Process Description Av. Flow Max Flow Type of Discharge
(continuous, batch, none)
Wastewater
Discharge Information (continued)
If the business contains “Categorical”
Processes, please complete the following:
No. Regulated Process Av. Flow Max. Flow Type of Discharge
(continuous, batch, none)
No. Unregulated Process Av. Flow Max. Flow Type of Discharge
(continuous, batch, none)
No. Dilution Av. Flow Max. Flow
Type of Discharge
(continuous, batch, none)
6. Provide
the following Total Toxic Organics (TTO) information:
a. Does (or will) this facility use any of
the toxic organics that are listed under the TTO standard of the Categorical
Pretreatment Standards published by the EPA? ( )
Yes ( ) No
b. Has a “Baseline Monitoring Report”
(BMR) been submitted which contains TTO information? (
) Yes (
) No
c. Has a “Toxic Organic Management Plan”
(TOMP) been developed? If so, please
include a copy. (
) Yes ( ) No
Wastewater
Discharge Information (continued)
7. Does the facility have (or will it have) automatic sampling or wastewater flow metering equipment?
Current: Sampling
( ) Yes (
) No
Metering (
) Yes (
) No
Future: Sampling (
) Yes (
) No
Metering (
) Yes (
) No
If so, please indicate location(s)
of this equipment on the Schematic Diagram requested in paragraph 4 of this
section, and describe the equipment below:
8. Are any process changes or expansions
planned during the next two years that could alter wastewater volumes or
characteristics? Consider processes that
may affect the discharge. ( )
Yes ( ) No
If yes, briefly
describe these changes and their effects on the wastewater volume and characteristics (attach additional sheets
as needed):
9. Are any materials or water reclamation systems in use or planned?
( ) Yes ( ) No
If yes, briefly describe
recovery process, substance recovered, percent recovered, and the concentration
in the spent solution. Submit a flow
diagram for each process (attach additional sheets as needed):
SECTION F – CHARACTERISTICS OF DISCHARGE
1. All current Significant Industrial Users are required to submit monitoring data on all pollutants that are regulated specific to each process. Use the tables provided as attachments to this section to report the analytical results. DO NOT LEAVE BLANKS.
2. For all other (non-regulated) pollutants, indicate whether the pollutant is known to be present (P), suspected to be present (S), or known not to be present (O), by placing the appropriate letter in the column for average reported values. Indicate the sample location and type of analysis used (methods must conform to 40 CFR Part 136, if they do not, indicate what method was used).
3. New dischargers should use the table to indicate what pollutants will be present or are suspected to be present in wastewater by placing a P (expected to be present), S (may be present), or O (will not be present) under the “Average Reported Values”.
SEE ATTACHMENTS 1-A THROUGH 1-E.
SECTION G
– WASTEWATER TREATMENT
1. Is any form of wastewater treatment (see list below) practiced at this facility?
( ) Yes ( ) No
2. Is any form of wastewater treatment (or changes to existing wastewater treatment) planned for this for this facility within the next three years? ( ) Yes ( ) No
If
yes, please describe:
3. Wastewater treatment devices or processes used or proposed to be used for treating wastewater or sludge (check all that apply):
( ) Air Flotation
( ) Centrifuge
( ) Chemical precipitation
( ) Cyclone
( ) Filtration
( ) Flow Equalization
( )
Grease or Oil Separation (type: )
( ) Grease Trap
( ) Grinding
( ) Grit Removal
( ) Ion Exchange
( ) Neutralization, pH correction
( ) Ozonation
( ) Reverse Osmosis
( ) Screening
( ) Sedimentation
( ) Septic Tank
( ) Solvent Separation
( ) Spill Protection
( ) Sump
( )
Biological (type: )
( ) Rainwater diversion or collection
( )
Other Chemical Treatment (type: )
( ) Other Physical Treatment (type: )
( ) Other (type: )
Wastewater Treatment (continued)
4. Describe
the pollutant loadings, flowrates, design capacity, physical size, and
operating procedure of each treatment device or process checked above (attach
additional sheets as needed):
5. Attach a process flow diagram for each existing treatment system. Include process equipment, by-products, by-product disposal method, waste and by-product volumes, and design /operation conditions.
6. Describe
any changes in treatment or disposal methods planned or under construction for
the wastewater discharge to the public sewer.
Please include estimated completion dates:
7. Does the facility have a wastewater treatment operator? ( ) Yes ( ) No
If yes: Operator Name:
Title:
Phone:
Full Time (specify hours):
Part Time (specify hours):
8. Please include a copy of the “Standard Operating Procedures” for the wastewater treatment equipment, if applicable.
9. Does a written maintenance schedule for the wastewater treatment equipment exist? ( ) Yes ( ) No
SECTION H –
FACILITY OPERATIONAL CHARACTERISTICS
1. Shift Information:
Work Days: ( ) ( ) ( ) ( ) ( ) ( ) ( )
M T W Th F Sat Sun
Shifts per Day :
Employees per 1:
Shift: 2:
3:
Start and end times for each shift: 1: 2: 3:
2. Indicate whether business is :
( ) Continuous through the year
( ) Seasonal (if seasonal, circle the months of the year during which the business operates)
J F M A M J J A S O N D
Comments:
3. Indicate whether the facility discharge is:
( ) Continuous through the year
( ) Seasonal (If seasonal, circle the months of the year during which discharge occurs)
J F M A M J J A S O N D
Comments:
4. Does the facility shut down for scheduled work stoppages? ( ) Yes ( ) No
If yes, indicate the reasons and period of shut down:
Facility Operational Characteristics (continued)
5. List types and amounts of raw materials used or planned to be used:
Type: Amount:
6. List type and amount of chemicals used or planned to be used (include copies of appropriate Material Safety Data Sheets):
Type: Amount:
7. Building Layout Diagram:
a. Provide a scale drawing identifying location of each building on premises.
b. Show all water meters, storm drains, numbered unit processes, and each
connection to public sewers. Number each existing or proposed sewer
connection.
c. A blueprint showing the above information may be substituted in lieu of a
drawing.