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Page 1 of 18 CITY OF FLAGSTAFF INDUSTRIAL WASTEWATER DISCHARGE PERMIT APPLICATION FORM Note: Please read all attached instructions prior to completing this application. Return to City of Flagstaff Industrial Waste Office with a $1,250.00 fee for the permit. Failure to submit the fee will result in rejection of your application. SECTION A - GENERAL INFORMATION 1. Facility Name: a. Operator Name: b. Is the operator identified in 1.a., the owner of the facility? Yes [ ] No [ ] If, no, provide the name and address of the operator and submit a copy of the contract and/or other documents indicating the operator's scope of responsibility for the facility. 2. Facility Address: Street: City: State: Zip: 3. Business Mailing Address: Street / P.O. Box: City: State Zip: 4. Designated signatory authority of the facility: [Attach similar information for each authorized representative] Name: Title: Address: City: State: Zip: Phone 5. Designated facility contact: Name: Title: Phone ---PAGE BREAK--- Page 2 of 18 SECTION B - BUSINESS ACTIVITY 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 [ ] Battery Manufacturing [ ] Builders Paper and Board Mills [ ] Carbon Black Manufacturing [ ] Cement Manufacturing [ ] Coal Mining [ ] Coil Coating [ ] Copper Forming [ ] Dairy Products Processing [ ] Electronic Components Manufacturing [ ] Electroplating [ ] Explosives Manufacturing [ ] Feedlots [ ] Ferroalloy Manufacturing [ ] Fertilizer Manufacturing [ ] Foundries (Metal Molding and Casting) [ ] Fruits and Vegetables Processing [ ] Glass Manufacturing [ ] Grain Mills [ ] Gum and Wood Chemicals Manufacturing [ ] Hospitals [ ] Inorganic Chemicals Manufacturing [ ] Iron and Steel Manufacturing [ ] Leather Tanning and Finishing [ ] Meat Products Processing [ ] Metal Finishing [ ] Mineral or Ore Mining [ ] Nonferrous Metals Forming [ ] Nonferrous Metals Manufacturing [ ] Oil and Gas Extraction [ ] Organic Chemicals Manufacturing [ ] Paint and Ink Formulating [ ] Paving and Roofing Manufacturing [ ] Pesticides Manufacturing [ ] Petroleum Refining [ ] Pharmaceutical Manufacturing [ ] Phosphate Manufacturing [ ] Photographic Processing [ ] Plastic and Materials Manufacturing [ ] Plastics Processing Manufacturing [ ] Porcelain Enameling [ ] Pulp, Paper, and Fiberboard Manufacturing [ ] Rubber Manufacturing [ ] Seafood Processing [ ] Soap and Detergent Manufacturing [ ] Steam Electric Power Generating [ ] Sugar Processing [ ] Textile Mills [ ] Timber Products Processing A facility with processes inclusive in these business areas may be covered by Environmental Protection Agency's (EPA) categorical pretreatment standards. These facilities are termed "categorical users". 2. Give a brief description of all operations at this facility including primary products or services (attach additional sheets if 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. ---PAGE BREAK--- Page 3 of 18 4. PRODUCT VOLUME: PAST CALENDAR YEAR Amounts Per Day (Daily Units) ESTIMATE THIS CALENDAR YEAR Amounts Per Day (Daily Units) (Brand name) Average Maximu m Average Maximu m SECTION C - WATER SUPPLY 1. Water Sources: (Check as many as are applicable) [ ] Private Well [ ] Surface Water Municipal Water Utility - City of Flagstaff [ ] Other (Specify): 2. Name on the water bill: Name: Street: City: State: Zip: 3. Water Service Account Number: ---PAGE BREAK--- Page 4 of 18 4. List average water usage on premise: [New facilities may estimate] Type Average Water Usage (GPD) Indicate Estimated or Measured 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 & lawn watering j. Other k. TOTAL OF A-J Section D - SEWER INFORMATION 1. a. For an existing business: Is the building presently connected to the public sanitary sewer system? [ ] Yes: Sanitary sewer account number [ ] No: Have you applied for a sanitary sewer hookup? [ ] Yes [ ] No b. For a new business: Will you be occupying an existing vacant building (such as in an industrial park)? [ ] Yes [ ] No (ii). Have you applied for a building permit if a new facility will be constructed? [ ] Yes [ ] No (iii). Will you be connected to the public sanitary sewer system? [ ] Yes [ ] No ---PAGE BREAK--- Page 5 of 18 2. List size descriptive location, and flow of each facility sewer which connects to the City's sewer system. (If more than three, attach additional information on another sheet.) Sewer Size Descriptive Location of Sewer Connection or Discharge Points Average Flow (GPD) SECTION E - WASTEWATER DISCHARGE INFORMATION 1. Does (or will) this facility discharge any wastewater other than from restrooms to the City sewer? [ ] Yes If the answer to this question is "yes", complete the remainder of the application. [ ] No If the answer to this question is "no", skip to Section I. 2. Provide the following information on wastewater flow rate. [New facilities may estimate] a. Hours/Day Discharged 8 hours/day): SAT____ SUN____ b. Hours of Discharge 9AM to 5PM): SAT____ SUN____ c. Peak hourly flow rate (GPD) d. Maximum daily flow rate (GPD) e. Annual daily average (GPD) 3. If batch discharge occurs or will occur, indicate: [New facilities may estimate] a. Number of batch discharge per day b. Average discharge per batch (GPD) c. Time of batch discharges at (days of week) (hours of day) d. Flow rate gallons/minute e. Percent of total discharge ---PAGE BREAK--- Page 6 of 18 4. Schematic Flow Diagram - For each major activity in which wastewater is or will be generated, draw a diagram of the flow of materials, products, water, and wastewater from the start of the activity to its completion showing all unit processes. Indicate which processes use water and which generate wastestreams. Include the average daily volume and maximum daily volume of each wastestream [new facilities may estimate}. If estimates are used for flow data this must be indicated. Number each unit process having wastewater discharges to the community sewer. Use these numbers when showing this unit processes in the building layout in Section H. This drawing must be certified by a State Registered Professional Engineer. Facilities that checked activities in question 1 of Section B are considered Categorical Industrial Users and should skip to question 6. 5. For Non-Categorical Users Only: List average wastewater discharge, maximum discharge, and type of discharge (batch, continuous, or both), for each plant process. Include the reference number from the process schematic that corresponds to each process. [New facilities should provide estimates for each discharge]. No. Process Description Average Flow (GPD) Maximum Flow (GPD) Type of Discharge (batch, continuous, none) ANSWER QUESTIONS 6 & 7 ONLY IF YOU ARE SUBJECT TO CATEGORICAL PRETREATMENT STANDARDS 6. For Categorical Users: Provide the wastewater discharge flows for each of your processes or proposed process. Include the reference number from the process schematic that corresponds to each process. [New facilities should provide estimates for each discharge]. No. Regulated Process Description Average Flow (GPD) Maximum Flow (GPD) Type of Discharge (batch, continuous, none) ---PAGE BREAK--- Page 7 of 18 No. Unregulated Process Description Average Flow (GPD) Maximum Flow (GPD) Type of Discharge (batch, continuous, none) No. Dilution Description Average Flow (GPD) Maximum Flow (GPD) Type of Discharge (batch, continuous, none) 7. For Categorical Users Subject To Total Toxic Organic (TTO) requirements: Provide the following (TTO) information. a. Does (or will) this facility use any of the toxic organics that are listed under the TTO standard of the applicable categorical pretreatment standards published by EPA? [ ] Yes [ ] No b. Has a baseline monitoring report (BMR) been submitted which contains TTO information? [ ] Yes [ ] No c. Has a toxic organics management plan (TOMP) been developed? [ ] Yes [ ] No ---PAGE BREAK--- Page 8 of 18 8. Do you have, or plan to have, automatic sampling equipment or continuous wastewater flow metering equipment at this facility? Current: Flow Metering [ ] Yes [ ] No [ ] N/A Sampling Equipment [ ] Yes [ ] No [ ] N/A Planned: Flow Metering [ ] Yes [ ] No [ ] N/A Sampling Equipment [ ] Yes [ ] No [ ] N/A If so, please indicate the present or future location of this equipment on the sewer schematic and describe the equipment below: 9. Are any process changes or expansion planned during the next three years that could alter wastewater volumes or characteristics? Consider production processes as well as air or water pollution treatment processes that may affect the discharge. [ ] Yes [ ] No, (skip question 10) 10. Briefly describe these changes and their effects on the wastewater volume and characteristics: (Attach additional sheets if needed.) 11. Are any materials or water reclamation systems in use or planned? [ ] Yes [ ] No, (skip question 12) 12. 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 if needed.) ---PAGE BREAK--- Page 9 of 18 SECTION F - CHARACTERISTICS OF DISCHARGE All current industrial users are required to submit monitoring data on all pollutants that are regulated specific to each process. Use the tables provided in this section to report the analytical results. DO NOT LEAVE BLANKS. For all other (non-regulated) pollutants, indicated whether the pollutant is known to be present suspected to be present or known not to be present by placing the appropriate letter in the column for average reported values. Indicate on either the top of each table, or on a separate sheet, if necessary, the sample location and type of analysis used. Be sure methods conform to 40 CFR Part 136; if they do not, indicate what method was used. New discharges should use the table to indicate what pollutants will be present or are suspected to be present in proposed wastestreams by placing a P (expected to be present), S (may be present), or O (will not be present) under the average reported values. Note: You will obtain the information for the table for section F from your last 5 years of laboratory samples that you have done for your last permit as required by the City of Flagstaff Industrial Waste Division. TABLE 1: POLLUTANTS OF CONCERN PRIORITY POLLUTANTS LIST (40 CFR 403, APPENDIX B) HEAVY METALS AND IORGANICS TOXIC ORGANICS: AROMATICS Antimony (Sb) Benzene Arsenic Benzene, chloro- Asbestos Benzene, 1,2-dichloro- Beryllium (Be) Benzene, 1,3-dichloro- Cadmium (Cd) Benzene, 1,4-dichloro- Chromium (Cr) Benzene, hexachloro-; HCB Copper (Cu) Benzene, ethyl- Cyanides (CN) Benzene, nitro- Mercury (Hg) Toluene Molybdenum (Mo) Toluene, 2,4-dinitro-; DNT Lead (Pb) Toluene, 2,6-dinitro- Nickel (Ni) Benzene, 1,2,4-trichloro- Selenium (Se) Silver (Ag) Thallium (Tl) TOXIC ORGANICS: POLYNUCLEAR AROMATIC HYDROCARBONS (PAHs) Zinc (Zn) 2-Chloronaphthalene TOXIC ORGANICS: ETHERS Benzo anthracene Ether, bis(2-chloroethyl) Benzo fluoranthene; B(b)F Ether, bis(2-chloroisopropyl) Benzo fluoranthene; B(k)F Ether, 2-chloroethyl vinyl Benzo pyrene; B(a)P Ether, 4-chlorophenyl phenyl Ideno (1,2,3-cd) pyrene; IP Ether, 4-bromophenyl phenyl Dibenzo (a,h) anthracene; DBA Bis (2-chloroethoxy) methane Benzo (ghi) perylene Acenaphthene TOXIC ORGANICS: PHTHALATES Phthalate, dimethyl; DMP Anthracene Phthalate, diethyl; DEP Phthalate, di-n-butyl; DBP Fluoranthene Phthalate, di-n-octyl; DOP Fluorene Phthalate, DEHP Naphthalene Phthalate, butyl benzyl; BBP Phenanthrene Pyrene TOXIC ORGANICS: NITROGEN COMPOUNDS Nitrosamine, dimethyl- TOXIC ORGANICS: PCB’s Nitrosamine, diphenyl- PCB-1016; Aroclor 1016 Nitrosamine, di-n-propyl- PCB-1221; Aroclor 1221 Benzidine PCB-1232; Aroclor 1232 Benzidine, 3,3'-dichloro- PCB-1242; Aroclor 1242 ---PAGE BREAK--- Page 10 of 18 Hydrazine, 1,2-diphenyl- PCB-1248; Aroclor 1248 Acrylonitrile PCB-1254; Aroclor 1254 PCB-1260; Aroclor 1260 TOXIC ORGANICS: PHENOLS Phenol TOXIC ORGANICS: HALOGENATED ALIPHATIC HYDROCARBONS Phenol, 2-chloro Phenol, 2,4-dichloro-; 2,4-DCP Methane, chloro-; methyl chloride Phenol, 2,4,6-trichloro- Methane, dichloro-; Methylene chloride Phenol, pentachloro-; PCP Methane, trichloro-; chloroform Phenol, 2-nitro- Methane, tetrachloro-; Carbon tetrachloride Phenol, 4-nitro- Methane, bromo methyl bromide Phenol, 2,4-dinitro-; 2,4-DNP Methane, dichlorobromo - Phenol, Methane, chlorodibromom- m-Cresol, p-chloro- Methane, tribromo bromoform o-Cresol, 4,6-dinitro-; DNOC Ethane, chloro- TOXIC ORGANICS: HALOGENATED ALIPHATIC HYDROCARBONS (CONTINUED) CONVENTIONAL POLLUTANTS: (LISTED IN 40 CFR 401.16 Ethane, 1,1-dichloro- Biochemical Oxygen Demand (BOD) Ethane, 1,2-dichloro- pH (Acid or Base) Ethane, 1,1,1-trichloro- Total Suspended Solids (TSS) Ethane, 1,1,2-trichloro- Oil and Grease (O&G) Ethane, 1,1,2,2-tetrachloro- Ethane, hexachloro- NONCONVENTIONAL POLLUTANTS OF CONCERN: (NOT LISTED AS TOXIC OR CONVENTIONAL) Ethylene, chloro-; Vinyl Chloride Ethylene, 1,1-dichloro-; 1,1-DCE Ammonia (NH3) Ethylene, trichloro-; TCE Chlorides (Cl-1) Ethylene, 1,2-trans-dichloro- Sulfides (S-2) Ethylene, tetrachloro-; Perchloroethylene Total Dissolved Solids (TDS) Propane, 1,2-dichloro- Phosphate (PO4) Propylene, 1,3-dichloro- Chemical Oxygen Demand (COD) Butadiene, hexachloro-; HCBD Cyclopentadiene, hexachloro-; TOXIC ORGANICS: PESTICIDES TOXIC ORGANICS: OXYGENATED COMPOUNDS Endrin aldehyde Heptachlor Acrolein Heptachlor epoxide Chlordane TOXIC ORGANICS: MISCELLANEOUS Toxaphene Isophorone alpha-BHC 2,3,7,8-tetrachlorodibenzo-p-dioxin; TCDD; dioxin beta-BHC gamma-BHC delta-BHC; Lindane Aldrin; HHDN Dieldrin; HEOD 4,4'-DDE 4,4'-DDT; p,p'-DDT 4,4'-DDD; p,p'-DDD; p,p'-TDE Endrin ---PAGE BREAK--- Page 11 of 18 SECTION G - 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 an existing wastewater treatment) planned for this facility within the next three years? [ ] No [ ] Yes, describe: 3. Treatment devices or processes used or proposed for treating wastewater or sludge (check as many as appropriate). [ ] Air flotation [ ] Centrifuge [ ] Chemical precipitation [ ] Chlorination [ ] Cyclone [ ] Filtration [ ] Flow equalization [ ] Grease or oil separation, type: [ ] Grease trap [ ] Grinding filter [ ] Grit removal [ ] Ion exchange [ ] Neutralization [ ] Ozonation [ ] Reverse Osmosis [ ] Screen [ ] Sedimentation [ ] Septic tank [ ] Solvent separation [ ] Spill protection [ ] Sump [ ] Biological treatment, type: [ ] Rainwater diversion or storage [ ] Other chemical treatment, type: [ ] Other physical treatment, type: [ ] Other, type: 4. Description Describe the pollutant loadings, flow rates, design capacity, physical size, and operating procedures of each treatment facility checked above. 5. Attach a process flow diagram for each existing treatment system. Include process equipment, ---PAGE BREAK--- Page 12 of 18 by-products, by-product disposal method, waste and by-product volumes, and design and operating conditions. 6. Describe any changes in treatment or disposal methods planned or under construction for the wastewater discharge to the sanitary sewer. Please include estimated completion dates. 7. Do you have a treatment operator? [ ] Yes [ ] No (if Yes,) Name: Title: Phone: Full time: (specify hours) Part time: (specify hours) 8. Do you have a manual on the correct operation of your treatment equipment? [ ] Yes [ ] No 9. Do you have a written maintenance schedule for your treatment equipment? [ ] Yes [ ] No ---PAGE BREAK--- Page 13 of 18 SECTION H - FACILITY OPERATIONAL CHARACTERISTICS 1. Shift Information Work Days Mon. Tues. Wed. Thur. Fri. Sat. Sun. [ ] [ ] [ ] [ ] [ ] [ ] [ ] Shifts per work day: Employees per 1st shift: 2nd 3rd Shift start 1st and 2nd times: 3rd day: 2. Indicate whether the business activity is: [ ] Continuous through the year, or [ ] Seasonal - Circle the months of the year during which the business activity occurs: J F M A M J J A S O N D COMMENTS: 3. Indicate whether the facility discharge is: [ ] Continuous through the year, or [ ] Seasonal - Circle the months of the year during which the business activity occurs: J F M A M J J A S O N D COMMENTS: ---PAGE BREAK--- Page 14 of 18 4. Does operation shut down for vacation, maintenance, or other reasons? [ ] Yes, indicate reasons and period when shutdown occurs: [ ] No 5. List types and amounts (mass or volume per day) of raw materials used or planned for use (attach list if needed): 6. List types and quantity of chemicals used or planned for use (attach list if needed). Include copies of Manufacturer's Safety Data Sheets (if available) for all chemicals identified. Chemical Quantity ---PAGE BREAK--- Page 15 of 18 7. Building Layout - Draw to scale the location of each building on the premises. Show map orientation and location of all water meters, storm drains, numbered unit processes (from schematic flow diagram), public sewers, and each facility sewer line connected to the public sewers. Number each sewer and show existing and proposed sampling locations. This drawing must be certified by a State Registered Professional Engineer. A blueprint or drawing of the facilities showing the above items may be attached in lieu of submitting a drawing on this sheet. SECTION I - SPILL PREVENTION 1. Do you have chemical storage containers, bins, or ponds at your facility? [ ] Yes [ ] No If yes, please give a description of their location, contents, size, type, and frequency and method of cleaning. Also, indicate in a diagram or comment on the proximity of these containers to a sewer or storm drain. Indicate if buried metal containers have cathodic protection. 2. Do you have floor drains in your manufacturing or chemical storage area(s)? [ ] Yes [ ] No If yes; Where do they discharge to? 3. If you have chemical storage containers, bins, or ponds in manufacturing area, could an accidental spill lead to a discharge to: (check all that apply). [ ] an onsite disposal system [ ] public sanitary sewer system (e.g. through a floor drain) [ ] storm drain [ ] to ground [ ] other, specify [ ] not applicable, no possible discharge to any of the above routes 4. Do you have an accidental spill prevention plan (ASPP) to prevent spills of chemicals or slug discharges from entering the Control Authority's collection systems? [ ] Yes - [Please enclose a copy with the application] [ ] No [ ] N/A, Not applicable since there are no floor drains and/or the facility discharge(s) only domestic wastes. 5. Please describe below any previous spill events and remedial measures taken to prevent their reoccurrence. ---PAGE BREAK--- Page 16 of 18 SECTION J - NON-DISCHARGED WASTES 1. Are any waste liquids or sludges generated and not disposed of in the sanitary sewer system? [ ] Yes, please describe below [ ] No, skip the remainder of Section J. Waste Generated Quantity (per year) Disposal Method 2. Indicate which wastes identified above are disposed of at an off-site treatment facility and which are disposed of on-site. 3. If any of your wastes are sent to an off-site centralized waste treatment facility, identify the waste and the facility. 4. If an outside firm removes any of the above checked wastes, state the name(s) and address(es) of all waste a. Permit No. (if applicable): b. Permit No. (if applicable): 5. Have you been issued a Federal, State, or local environmental permits? [ ] No [ ] Yes If yes, please list the permit(s): ---PAGE BREAK--- Page 17 of 18 SECTION K - AUTHORIZED SIGNATURES Compliance certification: 1. Are all applicable Federal, State, or local pretreatment standards and requirements being met on a consistent basis? Yes [ ] No [ ] Not yet discharging [ ] 2. If No: a. What additional operations and maintenance procedures are being considered to bring the facility into compliance? Also, list additional treatment technology or practice being considered in order to bring the facility into compliance. b. Provide a schedule for bringing the facility into compliance. Specify major events planned along with reasonable completion dates. Note that if the Control authority issues a permit to the applicant, it may establish a schedule for compliance different from the one submitted by the facility. Milestone Activity Completion Date ---PAGE BREAK--- Page 18 of 18 AUTHORIZED REPRESENTATIVE STATEMENT: 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 the person or persons who manage the system, or those persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belie, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. I am also aware that during the term of this permit, I must immediately report to the City of Flagstaff any significant changes to the information contained in this application. Name Title Date: Signature Phone: Name Title Date: Signature Phone: Name Title Date: Signature Phone: Name Title Date: Signature Phone: Name Title Date: Signature Phone: