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Pretreatment Prosram CITY OF JEROME Discharge Approval Application Please complete all questions; do not leave blanks (if not applicable, indicate with NA) A. CONTACT INFORMATION 1. Facility discharging wastewater: Name Street address Mailing address (if different from physical address) Teleohone number 2, Business owner: Name Mailing address Telephone number 3. Property owner: Name Mailins address Telephone number Manager or person responsible for daily facility operations: Name/title 4. 5. Telephone number Contact Person(s) in case of emergency: Name/title Telephone number Discharge Approval Application Page I ---PAGE BREAK--- Pretreatment Program B. BUSINESS / PROCESS INF'ORMATION l. Number of employees Normal operating schedule hours ofoperation days/week 2. Please describe business activities, including adescription of all services, operation processes, and types of wastes and wastewater generated. (If needed, extra sheets may be attached.) 3. Are any process changes or expansion planned during the next three years? YES _ NO _ Ifyes, attachaseparatesheettothisformdescribingthenatureofplannedchangesorexpansions. 4. Attach a list of all chemicals used, stored, or generated at the facility (see Attachment 5. If your facility employs or will be employing processes in any of the following listed Business Activities or Industrial Categories (regardless of whether they generate wastewater, waste sludge, or hazardous waste), place a check beside the activity lcategory (please check all that apply). Specify:_ I I Food/beveragepreparation of any kind (please attach menu) Other Business Activities Adhesives Auto repair Beverage bottler Carltruck wash Dairy Products (e.g. cheese mfg,, milk) Specify: Dentistry Dry cleaning Food/edible products processor (fresh pack, potato processor) Specify: Heavy equipment repair Hospital Lawn and fetilizing applicators Medical lab services Military installation Paint and ink Pesticide applicator Photo-film processing Printing and publishing S laughter/meat packin g/renderin g Waste recycle Other, Specify Discharge Approval Application Page 2 ---PAGE BREAK--- Pretreatment Program b. Industrial Categories Battery manufacturing Copper forming Electric and Electronic compounds mfg. Electroplating Inorganic chemicals Iron and steel Leather tanning and finishing Metal finishing Nonferrous metals mfg. Nonferrous metals forming Organic chemicals mfg. Pesticides mfg. Petroleum refining Pharmaceuticals Plastics and materials mfg. Plastics processing mfg. Pulp, paper, and fiberboard Rubber Textile mills Timber products (e.g. wood preserving, list operations) Silver Recovery Units Solvent Recovery Units Antifreeze Recycler Used Oil Burner Other NO 6. Industrial Classification number(s) {designate if SIC or NAICS} 7. What Pretreatment/Recycling equipment do you have? Equalization Grease Trap Grease Interceptor Oil/Sand Separator (sump) pH Adjustment C. WASTEWATER DISCHARGE INFORMATION l. Sewer Connections: a. Will you be occupying an existing building? YES Cooling water non-contact Washing (equipment wash b. Is the building presently connected to the public sewer system? YES _ NO _ a. If ves. sewer account # If no, have you applied for a sewer hookup? _ 2. Attach the following: (see Attachments B and C) a. Site plan showing location of facility, property boundaries, adjacent streets, sewers, connections and manholes, and any continuous flow monitoring and sampling equipment. b. Floor plan showing all locations of fixtures discharging to the sewer. Include all sinks, dishwashers, toilets, floor drains, sumps, grease oil/sand separators, process tanks, and any other sewer accesses. 3. Water use (check all that apply): Sanitary Boiler/cooling tower Irrigation Coolins water contact Air pollution control Contained in product Surface water Other (describe) Discharge Approval Application down) Waste hauler Page 3 ---PAGE BREAK--- 4. Water use and distribution - estimate the average quantity of water received and discharged daily (For new business, estimate flow) Supply Water volume per day Discharge water volume per day 5. For Categorical Facilities: Provide the following flow for each of your regulated processes or proposed regulated process (manufacturing process line covered by categorical pretreatment standards) Total plant flow in gallons per day (gpd) discharged to the sewer system. Average Maximum 6. Have you been issued a local, state, or federal wastewater environmental control permit to store, treat, transport, or discharge waters or liquid wastes? (e.g. waste generator or hauler, air quality, NPDES permit, etc.) YES NO If yes, list permits and dates of issue D. CERTIF'ICATION Confidentiality: Please indicate those sections of this application that you wish to remain confidential, and your basis for requiring confidentiality 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 gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system or persons directly responsible for gathering information, the information submitted is to the best of knowledge and belief, true, accurate and complete. I'm aware that there are significant penaltiesfor submittedfalse information, including the possibility offine or imprisonment for knowing violations. Signature: Date: Title: Printed Name: Discharge Approval Application Page 4 ---PAGE BREAK--- Pretreatment Prosram ATTACHMENT A CHEMICALS USED/STORED Business Name Generic Type Amount Used/Year Amount On Hand Chemical Constituents or Brand Names Example: Degreaser 3 gallons 45 gallons Trichloroethylene Discharge Approval Application Page 5 ---PAGE BREAK--- ATTACHMENT B SEWER CONNECTIONS PLAN Business Name Include: Location of facility, property boundaries, adjacent streets, sewers, connections, and manholes (sewer and storm). Discharge Approval Application Page 6 ---PAGE BREAK--- ATTACHMENT C PLUMBING DRAWINGS Business Name Include: All sinks, dishwasher, toilets, floor drains, sumps, grease interceptors lvaps, oil/sand separators, process tanks, and any other sewer accesses. Discharge Approval Application