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WASTEWATER PERMIT APPLICATION CITY OF FONTANA FOR OFFICE USE ONLY DEPARTMENT OF PUBLIC WORKS RECEIVED DATE: 16489 ORANGE WAY PERMIT NO.: FONTANA, CA 92335 Company Name: Telephone Number: ( ) Company Contact Person: (Person empowered by authorized representative to represent the Company, or party responsible for the proper completion of this survey form.) Mailing Address: Facility Address: _ _ Section A: Operation Description Days/Hours of Operations: What do you wash: (check all that apply) Cars Trucks Large equipment Engines Vehicle Undercarriage Parking Lots Sidewalks Trash Enclosures Building Exterior Other (please list): How many sites or vehicles are washed during a typical day: Is used wash water collected? Yes No If yes, Section B: Water Use Is water treated before use? Yes No If yes, how? Is water treated after use? Yes No If yes, how? Wastewater from this business goes to the following: (check all that apply) Sanitary Sewer Stormdrain Discharge to the ground Waste Hauler Evaporation Disposal Facility Waste Hauler or Disposal Facility Does water from this business undergo any treatment prior to discharge or disposal? Oil/Water Separator: Yes No Sand trap/Settling Tank: Yes No Filtration: Yes No pH Adjustment: Yes No Other: Yes No SHORT FORM SURVEY – MOBILE WASH OPERATIONS ---PAGE BREAK--- Section C: Chemical Use and Storage Please provide information on all chemicals (soaps, soaks, brighteners, sealants, etc.) kept in stock in quantities of one gallon or larger (if liquid), ten pounds or more (if dry). Attach a separate page if necessary. **Submit Safety Data Sheets for each chemical listed** Amount Stocked Amount Stored Spill Containment Product Brand Used Number of Containers Size of Containers Inside Outside Covered Do containers have secondary spill containment for leaks or spills? Section D: Certification I have personally examined and am familiar with the information submitted in this document and attachments. Based on 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. Authorized Representative – Print * Signature Date Job Title* Phone Number Email Address *Surveys must be signed as follows: Corporations - By a principle executive officer of at least the level of Vice-President. Partnership - By a General Partner. Sole Proprietorship - By the Proprietor. (Ref: CFR part 403.12[1]). Branch or franchise - Manager with decision making functions. Disclosure: Title 40 of the Code of Federal Regulations Part 403 Section 403.14 requires information provided in this questionnaire identifying the nature and frequency of discharge to 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 applicable State Law. Should a discharge permit be required for your facility, the information in this questionnaire may be used to issue the permit. For questions or comments, please contact the City of Fontana Public Works Department, Environmental Section, at (909) 350-6760. ---PAGE BREAK--- FACT SHEET Business Activities: Provide a detailed description of all activities that occur as a part of your daily Mobile Washing operation. This description must include a list of all equipment and Best Management Practices (BMP’s) in place to prevent the discharge of wastewater and/or other pollutants into the stormdrain system.