Industrial/Commercial Wastewater Survey

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Please correct the field(s) marked in red below:

1
Name of Business
 *
2
Mailing Address
 *
3
Facility Address
 *
4
Contact/Title
 *
5
Phone
 *
6
Email
 *
7
Typical Number of Employees
 *
8
Typical Hours of Operation
 *
Typical Hours of Operation
9
Typical Operational Days of the Week
 *
Typical Operational Days of the Week
10
Number of Employees per shift:
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Number of Employees per shift:
11
Give a brief description of the operations at this facility including raw materials, primary products, and services.
 *
12
List applicable Standard Industrial Classification (SIC) or North American Industry Classification System Code(s) for all processes.
List applicable Standard Industrial Classification (SIC) or North American Industry Classification System Code(s) for all processes.
13
Select all activities that occur at your facility. 
 *
Select all activities that occur at your facility.
14
Are you subject to any of the EPA industrial categories with pretreatment standards? (Reference Table 1)
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Are you subject to any of the EPA industrial categories with pretreatment standards? (Reference Table 1)
15
Do you have a National Pollutant Discharge Elimination System permit?  
Do you have a National Pollutant Discharge Elimination System permit?
16
Does your facility use any Priority Pollutants listed in Table 2?
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Does your facility use any Priority Pollutants listed in Table 2?
17

If your facility uses any Priority Pollutants listed in Table 2, list the type and amount of chemicals used in gallons per day, and your method of disposal. 

If your facility uses any Priority Pollutants listed in Table 2, list the type and amount of chemicals used in gallons per day, and your method of disposal.
18
Does an outside firm remove hazardous waste?
 *
Does an outside firm remove hazardous waste?
19
If an outside firm moves hazardous waste, list the name and address of all waste haulers and indicate the frequency of pick-up.
If an outside firm moves hazardous waste, list the name and address of all waste haulers and indicate the frequency of pick-up.
20
EPA Hazardous Waste Identification Number (if applicable):
21
Do you own and maintain a treatment or pretreatment facility?
 *
Do you own and maintain a treatment or pretreatment facility?
22
If you own and maintain a treatment or pretreatment facility please describe below:
23
Characteristics of your wastewater - If you believe the pollutant listed on the left may be present in your wastewater, check the "Believed Present" column.  If you don't believe the pollutant is present in your wastestream, check the "Believed Absent" column.
 *
Characteristics of your wastewater - If you believe the pollutant listed on the left may be present in your wastewater, check the "Believed Present" column. If you don't believe the pollutant is present in your wastestream, check the "Believed Absent" column.
Believed Absent Believed Present
pH less than 6.0 (acidic)
pH greater than 10.5 (basic)
High Temperature (>150°F)
Biochemical Oxygen Demand
Chemical Oxygen Demand
Total Suspended Solids
Ammonia
Phosphorus
Oil & Grease not from food
Phenols
Cyanide
Arsenic
Cadmium
Chromium
Copper
Lead
Mercury
Molybdenum
Nickel
Silver
Zinc
Organic Compounds (i.e. solvents)
24
Do you purchase or store any liquid chemicals in containers 30 gallons or larger?
 *
Do you purchase or store any liquid chemicals in containers 30 gallons or larger?
25
If you purchase or store any liquid chemicals in containers 30 gallons or larger, list the trade name, quantity stored, and use of each chemical.  
If you purchase or store any liquid chemicals in containers 30 gallons or larger, list the trade name, quantity stored, and use of each chemical.
26

In accordance with Title 40 of the Code of Federal Regulations, Part 403, Section 403.11, information and data provided in this survey which identified the nature and frequency of discharge shall be available to the public without restriction.  Request for confidential treatment of other information shall be governed by procedure specified in 40 CFR, Part 2.

This is to be signed by an authorized official of your firm after adequate completion of this form and review of the information by the signing official.

"I have personally examined and am familiar with the information submitted in this document and attachments.  Based upon my inquiry of those individuals immediately responsible for obtaining information reported herein, I believe that the submitted information is true, accurate, and complete.  I am aware that there are significant penalties for submitting false information, including possibility of fine and/or imprisonment."

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