Document Fontana_doc_398449c5b9

CITY OF FONTANA 16489 ORANGE WAY, FONTANA, CALIFORNIA 92335 COMMERCIAL/INDUSTRIAL WASTEWATER SURVEY AND PERMIT APPLICATION 1. Company name, mailing address, and telephone number: Phone 2. Address of production or manufacturing facility (Check if same ) Phone Fax 3. Person authorized to represent above named firm in official dealings with the City: Name Title Phone Email 4. Alternate person to contact concerning information provided herein: Name Title Email 5. Type of business (auto repair, machine shop, electroplating, warehousing, painting, meat packing, food processing, etc.): Note to Signing Official: In accordance with Title 40 of the Code of Federal Regulations Part 403 Section 403.14 and Section 26-23.7 of the City Code, information and data provided in this questionnaire which identifies the nature and frequency of discharge shall be available to the public without restriction. Requests for confidential treatment of other information shall be governed by procedures specified in 40 CFR Part 2 and Section 26-23.8 of the City Code. Should a discharge permit be required for your facility, the information specified in this questionnaire and additional information specified in a subsequent application for Wastewater Discharge Permit will be used by the City in developing a wastewater discharge permit. This is to be signed by an authorized official of your firm after 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 the information reported herein, I believe the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and/or imprisonment. Date Signature of Official Printed Name Title FOR OFFICE USE ONLY APPLICATION # PERMIT # ---PAGE BREAK--- 6. Provide a brief detailed description of the manufacturing, production, or service activities your firm conducts. 6a. Standard Industrial Classification Code(s) (SIC) for your facility. 7. Types of wastes generated: Maximum gallons per day . 1.  Domestic wastes, restroom  estimated  measured 2.  Cooling water, non-contact  estimated  measured 3.  Boiler/tower blowdown  estimated  measured 4.  Cooling water, contact  estimated  measured 5.  Process waste (Ex: grease/oil)  estimated  measured 6.  Food processing waste(cleaning food)  estimated  measured 7.  Equipment/facility washdown  estimated  measured 8.  Air pollution control unit  estimated  measured 9.  Storm water runoff  estimated  measured 10.  Other  estimated  measured TOTAL WASTES GENERATED 8. Where wastes are discharged: Maximum gallons per day . 1.  Sanitary sewer (all wastewater)  estimated  measured 2.  Storm drain or channel  estimated  measured 3.  Street  estimated  measured 4.  Ground  estimated  measured 5.  Surface water  estimated  measured 6.  Groundwater  estimated  measured 7.  Wastehauler(s) (grease/oil collected)  estimated  measured 8.  Evaporation  estimated  measured 9.  Other  estimated  measured TOTAL WASTES DISCHARGED (Must equal total wastes generated) 9. Is a Spill Prevention Control and Countermeasure Plan prepared for the facility? Attach copies of manifests or bill of ladings for liquid waste control.  Yes  No 10. Name, address and phone # of landlord/ property owner/ management Company: 11. Attach site and/or floor plan of facility showing details of process plumbing, sewer lines, appurtenances, etc. 12. Attach a copy of the last 4 water bills (If new business, send a copy of the first four water bills). ---PAGE BREAK--- SECTION B - FACILITY OPERATIONS CHARACTERISTICS B.1. Number of shifts per 24-hour day: . B.2. Starting time of each shift: AM/PM, AM/PM, AM/PM B.3. Total number of employees per shift: , , . SECTION C - WASTEWATER INFORMATION C.1. Pretreatment devices or processes used for treating wastewater or sludge (check as many as appropriate):  Clarifier, Size , Number of compartments , Sample chamber  Grease or Oil Separation, Type .  Grease Trap, Size , Sample chamber .  Other, Type . C.2. Provide Name and Address of Pumping Service: C.3. How often are pretreatment devices cleaned? (i.e. daily, ---PAGE BREAK--- FACT SHEET Business Activity Description: A detailed description of all business activities must be provided to sustain the information listed on the permit application. This description should specify the types and quantities of new materials used and waste materials generated during the course of daily business activities. Describe storage measures and methods of disposal for waste materials, including non-domestic wastewater, e.g., discharge to sewer, stored and/or hauled, type and size of storage containers, etc.