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Industrial Discharge Permit Application Rev 06/2007 Page 1 of 12 CITY OF FERNLEY PUBLIC WORKS DEPARTMENT INDUSTRIAL WASTEWATER DISCHARGE PERMIT APPLICATION REV 06/2007 ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 2 of 12 CITY OF FERNLEY-PUBLIC WORKS DEPARTMENT INDUSTRIAL WASTEWATER DISCHARGE PERMIT APPLICATION Section I Application and Facility Description Unless stated otherwise, all items are to be filled out completely. If items are not applicable, indicate by noting Name of Facility Mailing Address Address of Premises Chief Executive Officers Name of Title of Each Officer: Emergency Contact Information Name of Contact, Title and Facility Phone and Cell Phone Numbers: ”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, or those persons directly responsible for gathering the information, 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 fine and imprisonment” Printed Name of Signing Official Title Signature of Signing Official Date ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 3 of 12 Section II Plant Operations 1. Provide a detailed description of manufacturing processes, facilities or service activities provided on the premises, specifically those processes, which involve process wastewater or hazardous materials. Use additional sheets if necessary. 2. Principal raw materials used: 3. Chemicals and compounds used (Refer to Table 4. Solvents used: 5. Describe storage practices for the chemicals and solvents listed above: ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 4 of 12 6. List all products manufactured or services provided by your facility along with the corresponding SIC (Standard Industrial Code Number: PRODUCT OR SERVICE SIC CODE 7. If this facility is subject to Federal Categorical Pretreatment Standards, as per 40 CFR 403, what is the categorical classification(s): What is the Federal Categorical Compliance Date: 8. Has a baseline report been submitted? Yes No 9. Shift Information Shifts normally worked: Sunday Monday Tuesday Wednesday Thursday Friday Saturday 1st 2nd 3rd Average # of employees per shift 1st 2nd 3rd Shift start and end times 1st 2nd 3rd ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 5 of 12 TABLE 1 PRIORITY POLLUTANTS If you use, or dispose of, any of the items on the following two pages, mark them By the following methods: 1. = ITEMS IS USED AT THIS LOCATION 2. (DT) = DISPOSED OF, AFTER TREATMENT 3. (DW) = DISPOSED OF, WITHOUT TREATMENT TO THE FERNLEY SANITARY SEWER SYSTEM. 4. (DO) = DISPOSED OF, OFF SITE, AFTER BEING USED AND OR GENERATED, SUCH AS SLUDGE, LIQUID ETC. 5. (TU) = ITEM IS TOTALLY USED IN PRODUCTION; THEREFORE NO WASTE PRODUCT IS LEFT 6. (VU) = ITEM IS VAPORIZED IN USE, AND THEREFORE NO WASTE PRODUCT IS LEFT. An item may have several different markings after it, depending on the use, treatment and disposal of each, by your company. ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 6 of 12 TABLE 1 PRIORITY POLLUTANTS DERIVED FROM THE TOXIC POLLUTANTS WHICH ARE CITED IN 40 CFR 401.15 I General Chemistry Code VI Toxic Organics: phenols Code pH Phenol pH Temperature Phenol, 2-chloro II. Metals and Inorganics Phenol, 2-4dichloro; 2,4 DCP Antimony; Sb Phenol, 2,4,6-trichloro Arsenic; As Phenol, pentachloro; PCP Asbestos Phenol, 2-nitro Baryllium; Be Phenol, 4-nitro Cadmium; Cd Phenol, 2,4-dinitro; 2,4-DNP Chromium; Cr Phenol, 2,4-dimethyl Copper; Cu m-Cresol, p-cloro Cyanides; CN o-Cresol, 4,6-dinitrol; DNOG Lead; Pb VII Toxic Organics: Aromatics Mercury; Hg Benzene Nickel; Ni Benzene, chloro Selenium; Se Benzene, I,2-dichloro Silver; Ag Benzene, I,3-dichloro Thallium; TI Benzene, 1-4-dichloro Zinc; Zn Benzene, I,2,4-trichloro III. Toxic Organics; Ethers Benzene, hexachloro; HCB Ether, bis(2-chloroethyl) Benzene, ethyl Ether, bis(2-chloroisopropl) Benzene, nitro Ether, 2-chloroethyl vinyl Toluene Ether, 4-chlorophenyl pheny1 Toluene, 2,4-dinitor; DNT Ether, 4-bromophenyl pheny1 Toluene, 2,6-dinitro Bis (2-chloroathoxy) methane IV Toxic Organics: Phthalates VIII Toxic Organic; Polynuclear Aromatic Hydrocarbons Phthalate, dimethyl; DMP 2-Chloroaphthalene Phthalate, diethyl; DEP Benzo anthracene Phthalate, di-n-octyl; DOP Benzo fluoranthene; B(b)F Phthalate, DEHP Benzo fluoranthene; B(k)F Phthalate, butyl benzyl; BBP Benzo pyrene; BaP V Toxic Organic: Nitrogen Compounds Ideno (1,2,3-ed) pyrene; BaP Nitosamine, dimethyl Dibenzo (a,h) anthracene; DBA Nitrosamine, diphenyl Benzo (ghi) perylene Nitrosamine, di-n-propyl Acenaphthene Bensidine Benzidine, 3,3-dichloro Anthracene Hydrazine, 1,2-diphenyl Acrylonintrile Fluoranthene Fluorene Phenanthrene Pyrene ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 7 of 12 PRIORITY POLLUTANTS DERIVED FROM THE TOXIC POLLUTANTS WHICH ARE CITED IN 40 CFR 401.15 CONTINUED IX Toxic Organics: PCBs Code XI Toxic Organics; Pesticides Code PCB-1016; Aroclor 1016 alpha-Endosulfan PCB-1221; Aroclor 1221 Endosulfan sulfate PCB-1232; Aroclor 1232 Beta-Endosulfan PCB-1242; Aroclor 1242 Hexchlorocyclohexanes: PCB-1248; Aroclor 1248 alpha-BHC PCB-1254; Aroclor 1254 betha-BHC PCB-1260; Aroclor 1260 deltha-BHC Gamma-BHC; Lindane Aldrin; HHDN X Toxic Organic; Halogenated Hydrocarbons; Halogenated Aliphatic Dieldrin; HEOD Methane, chloro; Methyl chloride 4,4’-DDE Methane, dichloro; Methylene chloride 4,4’-DDT; p,p’-DDD: p,p’-TDP Methane, trichloro; Chloroform Endrin Methane, tetrachloro; Carbon tetrachloride Endrin aldehyde Ethane, chloro Heptachlor Ethane, 1,1 –dichloro Heptachlor epoxide Ethane, 1,2-dichloro Chlordance Ethane, 1,1,1-trichloro Toxaphene Ethane 1,1,2 –trichloro Ethane, 1,1,2,2-tetrachloro XII Toxic Organics: Oxygenated Compounds Ethane, hexachloro Acrolein Ethene, chloro; Vinyl chloride Propane, 1-2dichloro XIII Toxic Organics: Miscellaneous Propene 1,3-dichloro Isophorne Buradiene, hexachloro; HCBD 2,3,7,8-tetrachlorodibenzo-p- dioxin; TCDD, dioxin Cyclopentadiene, hexachloro; Methane, bromo; Methyl bromide Methane, dichlorobromo Methane, chlorodibromo Methane, tribromo; Bromoform Ethene, trichloro Ethene, 1,1-dichloro; 1,1-DCE Ethene 1,2-trans-dichloro Ethene, tetrachloro ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 8 of 12 TABLE 1 (ADDITIONAL ITEMS) OTHER POLLUTANTS Any Acids, Oils, Caustics, Fats, Grease or any other Chemicals NOT LISTED on the previous two pages that you Use, Generate, or Dispose of, at this location. List these below and Mark them according to the instruction age, titles Table 1. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 9 of 12 Section III Water Usage and Discharge Information 1. List intake water sources and volumes: Sources Volume Estimated/Measured Municipal Water System gallons/day Private Well gallons/day Surface Water gallons/day Other gallons/day 2. List average volume of discharge or water: Sources Volume Estimated/Measured City Sewer System gallons/day Natural Outlet (NPDES) gallons/day Water Hauler gallons/day Evaporation gallons/day Contained in Production gallons/day Other (Specify) gallons/day 3. Break down the water discharge to the sewer system into the following categories Sources Volume Estimated/Measured Process Wastestream #1 gallons/day Process Wastestream #2 gallons/day Process Wastestream #3 gallons/day Process Wastestream #4 gallons/day Sources Volume Estimated/Measured Contact Cooling gallons/day Non-Contact Cooling water gallons/day Sanitary Water gallons/day Boiler Blowdown gallons/day Other (Describe) gallons/day ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 10 of 12 4. Describe how each process and contact cooling Wastestream is generated (use additional sheets if necessary) 5. Is the discharge to the sewer: Continuous Batch If batch discharge, give the frequency of occurrence: What is the average volume in gallons of each batch: What is the number of batches each? 6. IMPORTANT: Provide a schematic of the plant flow showing process, sanitary, cooling stream, etc., and their point of entry into the sewer system. Indicate on the schematic where you collect effluent samples, and location of pretreatment facility. 7. Do you have automatic sampling equipment or continuous wastewater flow metering equipment currently in use or included in future plans? Flow Metering Yes No Current: Sampling Equipment Yes No Flow Metering Yes No Planned: Sampling Equipment Yes No ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 11 of 12 Section IV Pretreatment and Pollution Prevention (P2) 1. Describe any wastewater treatment equipment or processes in use: 2. Describe any additional pretreatment facilities and/or processes under consideration. Include a specific time schedule for completion: 3. Describe any pollution prevention activities that have taken place during the past five to ten (10) years such as: a) Closed Loop system b) Chemical Substitutions c) Water Conservation d) Process Changes e) Recycling f) Better Industrial Housekeeping g) Secure Chemical Storage Areas h) Floor Drains Closed Off i) Retaining Walls Built to Catch Spills, etc. j) Other Pollution Prevention P2 Activities ---PAGE BREAK--- Industrial Discharge Permit Application Rev 06/2007 Page 12 of 12 4. Do you dispose of any chemicals, solvents, sludges, or hazardous materials as a result of your processes? Yes No If so, provide a description of each material, giving the composition, annual quantity, and means of disposal: 5. If a private hauler is used to haul sludges/residuals, provide name and EPA Identification Number: 6. Where is the ultimate disposal site for sludges/residuals? 7. Do you have copies of manifests for waste hauled off site? Yes No 8. Do you have a spill prevention, containment and control plan (SPCC) for your facility? Yes No 9. Do you have a solvent management plan for your facility? Yes No 10. Do you have a certified operator for your pretreatment facility? Yes No If yes: Address: Certification Number: