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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 1. 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--- 5. Provide a brief detailed description of the manufacturing, production, or service activities your firm conducts. 6a. Standard Industrial Classification Code(s) (SIC) for your 6. 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 to sewer estimated measured 10. Other estimated measured TOTAL WASTES GENERATED 7. 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) estimated measured 8. Evaporation estimated measured 9. Other estimated measured TOTAL WASTES DISCHARGED (Must equal total wastes generated) 8. 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 and address of waste 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). SECTION B - FACILITY OPERATIONS CHARACTERISTICS B.1. Number of shifts per 24-hour B.2. Starting time of each shift: AM/PM, AM/PM, AM/PM B.3. Total number of employees per shift: , , ---PAGE BREAK--- NOTE: Information for the following items must be completed for each product line. Attach additional sheets if necessary. B.4. Principal product(s) produced: B.5. Raw materials and process additives B.6. Product process: Batch, Continuous, Both % batch, % continuous B.7. Hours of operation: AM/PM to AM/PM Continuous B.8. Is production subject to seasonal variation? Yes No B.9. Are any process changes or expansions planned during the next three years? Yes No If yes, describe the nature of planned changes or expansions on a separate sheet. B.10. Attach site and/or floor plan of facility showing details of process plumbing, sewer lines, connections, and appurtenances (including non-reclaimable waste line, if applicable). B.11a. Indicate total area of property (in acres): B.11b. Do you have a current Storm Water Pollution Prevention Plan? Yes No If yes, please send a copy to the City of Fontana. If no, one may need to be prepared. Check with The City of Fontana, NPDES Coordinator. B.12. Do you use a water conditioning unit (softener or demineralizer)? Yes No If yes, is conditioning unit regenerated onsite: Yes No If yes, name chemical(s) and amount used for regeneration: pounds/month pounds/month B.13. Do you use solvent degreasers (parts washers)? Yes No If yes, are you aware of Air Quality Management District (AQMD) Rule 1171? Yes No Effective date (1/1/1999)_____ 50 gm/L VOC Limit______ If yes, have you converted to a Low VOC System (Water-based)? Yes No Date converted__________ System/Material If not, when do you plan to convert? Name and address of ---PAGE BREAK--- SECTION C - WASTEWATER INFORMATION C.1. If your facility employs processes in any of the industrial categories or business activities listed below and any of these processes generate wastewater or waste sludge, place a check beside the category or activity. 1. Industrial Categories Adhesives Nonferrous Metals Aluminum Forming Ore Mining Anodizing Organic Chemicals Automobile Maintenance and Repair Paint & Ink Battery Manufacturing or Reclaiming Pesticides Coal Mining Petroleum Refining Coil Coating Pharmaceuticals Copper Forming Photographic Supplies Electric & Electronic Components Plastic & Materials Electroplating Plastics Processing Explosives Manufacturing Porcelain Enamel Foundries Printed Circuit Board Manufacturing Gum & Wood Chemicals Printing & Publishing Inorganic Chemicals Pulp & Paper Iron & Steel Rubber Laundries Soaps & Detergent Leather Tanning & Finishing Steam Electric Mechanical Products Textile Mills Metal Etching or Chemical Milling Timber Metal Coating (Chromating, Phosphating, Coloring, Passivating) 2. Business Activities Beverage Bottler Dairy Products Food/Edible Products Processing Restaurant Slaughter/Meat Packaging/Rendering C.2. Pretreatment devices or processes used for treating wastewater or sludge (check as many as appropriate): Air Floatation Biological Treatment, Centrifuge Chemical Precipitation Chlorination Clarifier, Size , Number of compartments , Sample chamber Cyclone Filtration Flow Equalization, Capacity Grease or Oil Separation, Grease Trap, Size , Sample chamber Grit Removal Ion Exchange Neutralization, pH Correction Ozonation Rainwater Diversion or Storage Reverse Osmosis Screen Septic Tank, Solvent Separation Spill Protection ---PAGE BREAK--- Sump, Other Chemical Treatment, Other Physical Treatment, Other, No Pretreatment Provided C.3. If any wastewater analyses have been performed on the wastewater discharge(s) from your facilities, attach a copy of the most recent data to this survey/application. Be sure to include the data of the analysis, name of laboratory who performed the analysis, and sampling location(s) (attach sketches, plans, etc. as necessary). SECTION D - OTHER WASTES D.1. Are any liquid wastes or sludge from this firm disposed of by means other than discharge to the sewer system? Yes No If yes, complete items D.2 and D.3. If no, go on to Section E. D.2. These wastes may be best described as: Estimated Gallons or Pounds/Year Acids and Alkalines Heavy Metal Sludges Inks/Dyes Oil and/or Grease Paints Pesticides Plating Wastes Solvents/Thinners Other Hazardous Wastes (specify): D.3. For the above checked wastes, does your company practice: Onsite Storage Offsite Storage Briefly describe the method(s) of storage or disposal checked above. ---PAGE BREAK--- SECTION E - ONSITE CHEMICAL STORAGE AND USE Complete items 1 through 8 for all chemicals in current or past use. Use additional sheets if necessary. 1. Chemical 2. Common/Trade 3. Method of Storage: Underground Tank Aboveground Tank Barrels Other (specify) 4. Quantity 5. Method of Waste Disposal: Sewer Hauled Onsite 6. Is waste treated prior to disposal? Yes No If yes, 7. Is waste stored prior to disposal? Yes No 8. Is there secondary containment for chemical(s)? Yes No 1. Chemical 2. Common/Trade 3. Method of Storage: Underground Tank Aboveground Tank Barrels Other (specify) 4. Quantity Stored: 5. Method of Waste Disposal: Sewer Hauled Onsite 6. Is waste treated prior to disposal? Yes No If yes, describe: 7. Is waste stored prior to disposal? Yes No 8. Is there secondary containment for chemical(s)? Yes No 1. Chemical 2. Common/Trade 3. Method of Storage: Underground Tank Aboveground Tank Barrels Other (specify) 4. Quantity Stored: 5. Method of Waste Disposal: Sewer Hauled Onsite 6. Is waste treated prior to disposal? Yes No If yes, describe: 7. Is waste stored prior to disposal? Yes No 8. Is there secondary containment for chemical(s)? Yes No ---PAGE BREAK--- FACT SHEET Process Description: A detailed description of all manufacturing and pretreatment operations must be provided to sustain the information listed on the permit application. This description should specify the types and quantities of raw materials used in each step of the operation as well as the sequence of steps followed during wastewater producing and pretreatment operations. Include types and quantities of untreated and pretreated wastewater and method of disposal, e.g., discharge to sewer, stored and/or hauled, etc. Specify each step of the process the wastewater will be generated.