Full Text
INDUSTRY DISCHARGE QUESTIONNAIRE New Business Form G Renewal Form G Section: 1 Name of Business: Property Address: (street, city, zip) Mailing Address: (street, city, zip) Contact Person: (Name) Contact Person: (Title) Phone Facility is: Owned: G Leased: G Home Business: G Other: Check the appropriate box’s which may apply to your business or give a brief description below of the business products or service’s provided; Auto-body Auto-repair Auto-sales Car Wash Dental Dry Cleaner Machine Shop Medical Office Only Restaurant / Fast Foods Screen Printer / Printing Warehouse / Storage Other Required; Brief Description of business: Section: 2 Average Number of Employees: Afternoon:__________ Night: Total: Types of Waste Water Discharges; other than SANITARY WASTEWATER (restrooms) check the box’s below which may apply to your business Non-Contact Cooling Water Contact Cooling Water Equipment Wash Down Boiler Blow Down Other Discharges; Explain: List Expected Daily Water Use in Gallons Per Day (GPD): Section: 3 Are any of your process discharges regulated by Federal Categorical Discharge Standards? Yes G No G If yes, list Standards: Code of Federal Regulations (CFR) _ Will any chemicals be used or stored on site? Yes G No G If yes, list chemicals that will be on site in quantities of 55 gallons or 500 lbs or more on the back of this form. Will any hazardous waste be generated at this facility? Yes G No G If yes, list types on the back of this form. Any Questions please call Central Valley Water Reclamation Facility Industrial Pretreatment Department (801) 973-9100 I have personally examined and am familiar with the information submitted in this report and any attachments. Based on my inquiry of those individuals immediately responsible for obtaining the information reported herein is true, accurate, and complete Signature: Date: ( FOR C.V.W.R.F. USE ONLY ) Business Classification: ( ) Is there a (GOSI) Installed at this location: Yes G No G Is a (GOSI) Needed at this location: Yes G No Reviewed by: (CV) Date: ---PAGE BREAK--- CHEMICALS USED CHEMICAL NAME AMOUNT STORED AMOUNT USED HAZARDOUS WASTES NAME EXPECTED GENERATION QUANTITY DISPOSAL METHOD February 25 2015