User's Site Address (if different than mailing address)
City
State
Zip
City
State
Zip
User's Phone:
6. Responsible Person Name
Title
7. Responsible 2 Person Name
Title
8. Owner/Parent Company Name (top) and Address(below)
Local U.S. EPA ID Numbers
Parent Company U.S. EPA ID Numbers
City
State
Zip
Facility's Phone:
If 7B/7C/7D clicked, on a submission, fill entire form. If not, proceed to signature
7A. No changes from previous submission
7B. Increase or decrease of personnel by 5 % or more
7C. Change in throughput (>5 %), process, feedstock or raw material
7D. New or original submission refiled
Date operations began
Month
Day
Year
8. Types of chemicals handled
9. Discharged to sanitary sewer
10. If not, where discharged?
Other chemicals, not listed below-list in last column
List chemicals,separated by commas
Antifreeze/Glycol compounds
Petroleum Grease oils
Vegetable Grease oils
Acids/Corrosives
High Solids Wastes
Solvents (incl. cleaning solvents)
Flammables/Explosives
Pesticides/Herbicides
Phenols
Cyanides
Metals/Metal Solutions
Nitrogen containing chemicals
Organic Chemicals
Radioactive Chemicals
Hazardous waste
Hauled or Trucked wastes
High Temperature wastes
15. USER’S CERTIFICATION: I
hereby declare that the contents of this declaration are fully and
accurately described above. I certify that the contents of this declaration to be true and accurate, based on my direct knowledge or from persons responsible, authorized and delegated to supply me this information.
10A .Enter all applicable SIC codes separated by commas
10B. Enter all applicable NAICS codes separated by commas
10C. List all products or services separated by commas
11A. Daily Production or service-number of units
11B. Peak flow WW, GPM
11C. Average daily flow WW, GPM
11D. Number of employees
hrs/day
d/wk
wks/yr
12. Methods of waste disposal
Sanitary sewer
Direct discharge to surface water body
Septic tank/leach field
Hauled offsite
Storm sewer
No wastewater generated
Other
If other, list:
13. Contractor Authorized to work at facility
Contractor 1 Printed/Typed Name
License number (expiry date on the right)
Month
Day
Year
Alternate Contractor Printed/Typed Name
License (expiry date on the right)
Month
Day
Year
14. Pretreatment-Do you treat the wastewater prior to discharge?
14a. Pretreatment Indication Space
pH adjustment
Grease separation(trap/interceptor)
Oil/water separation
Sands sedimentation
Metals treatment
Flow equalization
Other treatment
Other treatment 2
Other treatment 3
Secondary Containment
Floor drains to sewer
Toxic spill potential to sewer
Spill Response Plan
Spill Response Equipment
Pretreatment Supervisor Phone:
14 B. Pretreatment inspection-most recent regulatory agency inspection by:
Month
Day
Year
Designated Facility Owner or Operator:
Printed/Typed Name
Title
Signature
Month
Day
Year
HAZARDOUS WASTE DISCHARGE REPORTING NOTIFICATION
This notification is intended to inform your business of their obligations under federal law, 40 CFR §403.12(p). These requirements are for the reporting discharges of hazardous waste to the sanitary sewer.
40 CFR §403.12(p)(1): The User shall notify the POTW, the EPA Regional Waste Management Division Director, and State hazardous waste authorities in writing of any discharge into the POTW of a substance, which, if otherwise disposed of, would be a hazardous waste under 40 CFR Part 261. Such notification must include the name of the hazardous waste as set forth in 40 CFR Part 261, the EPA hazardous waste number, and the type of discharge (continuous, batch, or other). The District is requiring this notification for any discharge of hazardous waste to the sanitary sewer system and the report shall be made immediately or immediately of learning of the discharge.
In the case of any notification made under this part, the Industrial User shall certify that it has a program in place to reduce the volume and toxicity of hazardous wastes generated to the degree it has determined to be economically practical.