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Home My WebLink AboutWASTEWATER PERMITTING PROGRAM - 05-00295 - Design Intelligence - New Buildingyin of f EXBURG A' W-RJ1'} ; M IL COQ 14 aurin uenTer �HU Box 280) Rexburg, Idaho 83440 Wwwi re x rn Phone: 208-359-3020 X313 Fax: 208-359-3022 la irrex b ura. nrn TO: All Industrial Users Date form issued: FROM: CITY OF REXBURG Wastewater Department Subject:1Cty of Rexburg Industrial Wastewater permitting program To Whom It May Concem: All industries that discharge Tion -domestic wastewater the C'ty o� Rexburg�s Danita sewer shall complete the attachery d data. disclosure form. The purpose of this form is to develop a baseline monitoring report of your facility. This znformatioaccordinlocal n will be used to categorize your ze fac'hIty g to federal, state, and ordinances and regulations. If your facihty is deterilu'ned to be a significant industrial user then further sections of this data disclosure foam will be0requred to be f�Iled out. And for all significant industrial dischargers an industrial wastewater acceptance permit will be issued as �required, this permit sets limits on the amount of dzscharg� and any pollutants if acceptable. You will be advised as to the classification of your facility. Please take the time and fill out this form and submit it back within 18Q days to Siege Murphy P.O. Bax 280 Rexburg;, ID 83 4 4 4. If' yQu need further 0 assistance or need help in filling out this form da contact Stege at 359-3035. Thank you for your cooperation. Sincerely, CITY OF REXBURG Frani operator / Pretreatment coordinator I nositate to I r VO {General Instruction Sheep This handout is section I and should be filled out bv all existingand P-pwIosed mew non- domestic fac7lities. { Industria] and commercial estahiishments� ether sectzan�l� be re�u�red only if the effected facility has a process wastewater discharge{ s �, proposes to discharge process wastewaterfs3 O.c. the wastewater is not domestic in origin} . These additional sections will be forwarded if required, The City will be ver' ry.ing the data contained zn the returned foni-is through phone calls and site visits. Please take the time to fill out the fon-nf sl thoroughly and adequately. f Process wastewater also includes such items as spent solvents and chemicals dumped dawn the floor drains and sinks}. Section 1- General Infomiation: All questions should be answered. Information should be type written or clearly printed. Attached any requested ffiformation as needed. Additional sheets may be attached if necessary. Estimate the average number of office and production employees count for each shift Signing official must have the authorization to provide such information an behalf of the company, corporation, or partnership. If necessary. Simply sign this form and submit it to the city at the address shown below: Proposed mew businesses must insure to answer question number #25. Attachment A}: Listing of toxic pollutants �Priority Pollutantsi should be comp�et��i by all existing and proposed new non-domestic facilities. Attaclu-nent B}: listing of electroplating I metal finishin4, operations. To be completed by only those facilities engaged in the electroplating / metal finishing Attachment C 1 : Questionnaire on raw materials utilized. New Customers proposing to discharge wastewater Please supply as much information as possible providing the best estimates where appropriate. This section requires that the data for com7nei1cement operations and discharges be provided. 2 11 SECTION I CITY OF REXBURG INDUSTRIAL DATA DISCLOSURE FORM SECTION I CITY of R-EXBURG PRETREATMENT DATA DISCLOSURE FORM I. COMPANY NAME: IV 2. DIVISION:3. MAILING ADDRESS: (sraEeT oR r.o. eox) CITY: %2PC�ic 9 5. 6. 74- 8. 0 c . STATE:t1fc(el.11�.� � ZIP CODE: q��D FACILITY ADDRESS: (IF DTFIFFRF NT FRnrrt r,rn rr rnr STREET: CITY: STATE: ZIP CODE: PERSON TO BE CONTACTED ABOUT THIS INFORMATION: NAME0 : TITLE: PHONE #: -ids( R E 321'1715-�1 - 6&7 �a STANDARD INDUSTRIAL CLASSIFICATION ff (FOUR DIGIT SIC) FOR THE FACILITY. FOR EXISTING BUSINESSES: IF YOUR BUILDING PRESENTLY CONNECTED TO THE PUBLIC SEWER SYSTEM? YES NO IF YES, SEWER ACCOUNT NUMBER IF NO,, HAVE YOU APPLIED FOR A SEWER HOOKUP? IS YOUR BUSINESS PRESENTLY CONNECTED TO THE CITY STORM DRAIN SYSTEM? YES NO- FOR NEW BUSINESSES: WILL YOU BE OCCUPYING AN EXISTING VACANT BUILDING? ""tff HAVE YOU APPLIED FOR A BUYILDING PERMIT IF A NEW FACILITY WILL BE, CONSTRUCTED? /lp f -.. IF YES, BUILDING PER -MIT # WILL YOU BE CONNECTED TO TIDE PUBLIC SEWER SYSEM? WILL YOUR FACILITY BE CONNECTED TO THE CITY STORM D SYSTEM? YES_ 1/ NO 1 I [FORMAL OPERATING SCHEDULE: $crcr HRS/DAY DAYS/ EEK DOES THE FACILITY OPERATE CONTINUOUSLY TffROUGH`THE YEAR?��,c� IF NOT LIST THE NUMBER OF MONTHS IN THE YEAR YOU OPERATE. 10. IF YOUR FACILITY EMPLOYS OR WILL BE EMPLOYING PROCESSES IN ANY OF THE INDUSTRJALrl A 'T RIES OR BUSINESSES LISTED BELOW (REGARDLESS OF WHETHER THEY GENERATE WASTEWATER; WASTE SLUDGE, OR HAZARDOUS WASTES ACTIVITY. ), PLACE A CHECK BESIDE THE CATEGORY OR BUSINESS (*CHECK ALL THAT WILL OR. MAY APPLY) A. INDUSTRIAL CATEGORIES ALUMINUM FORMING BATTERY MANUFACTURING CAN MAKING COAL MINING COIL COATING COPPER FORMING ELECTRIC, AND ELECTRONIC COMPONENTS MFG. ELECTROPLATING (IF CHECKED, COMPLETE ATTACHMENT. -B) _ FOUNDRIES (METAL MOLDING AND CASTING) INORGANIC CHEMICALS _ IRON AND STEEL LEATHER TANNING AND FINISHING _ METAL FINISHING (IF CHECKED, COMPLETE ATTACHMENT B) _ NONFERROUS METAL MFG NONFERROUS METALS ORGANIC CHEMICALS FORMING _ PESTICIDES MFG PETROLEUM REFINING ............ PHARMACEUTICALS ........... PLASTICS AND SYTHETIC MATERIAL PLASTICS PROCESSING MFG PORCELAIN ENAMEL STEAM ELECTRONICS TEXTILE MILLS TIMBER PRODUCTS -S LIST OPERgTION: S MFG UCH AS WOOD PRESERVING N OTHER BUSINESS ACTIV ITES INCLUDE: _ ADHESIVES AUTO AND OTHER LAUNDRIES AUTO REPAIR BEVERAGE BOTTLEI DAIRY PRODUCTS (S UCH AS CHEESE MFG., MILK) SPECIFY `. EXPLOSIVES ivlF(: FOOD 1 EDIBLE PRODUCT PROCESSOR), SPECIFY,,- UCH PECIFY: S PROCESSOR (E.G., FRESH PACK, LAWN AND FERTILIZING APPLICATORS MILITARY INSTALLATIQN PAINTS AND INKS PESTICIDE APPLICATORS PHOTO -FILM PROCESSING RAILROAD YARD SLAUGHTER MEAT PACKING SOAP AND DETERGENT MFG WASTE RECYCLER OTHER, PLEASE SPECIFY; DO YOU OR WILL YOU DIS YES_ NO 1,� RENDERING i P CHARGE OILS GREASE OR, FATS TO THE PUBLIC SEWER? IS THERE OR WILL THERE BE AN OIL OR GRESE TRAP IN YO YES_ N 0 WHAT IS THE NOMAL FREQUENCY OF CLEANT TRAP ARF e nry i rte. r. _ UR SEWER CONNECTION? OUR OIL OR GREASE S LJ ►v �-�;, 1 r, vtc �Lui}[.�EFR+(]M THIS FIR2\4 D.iSPOSED QF BY MEAN ETHER THAN DISCHARGE TO THE SEWER SYSE VI? YES NO f.� THESE WASTES. MAY BE DESCRIBED AS. ACIDS AND ALKALIS HEAVY METALS SLUDGE INKS / DYES OILS AND 1 OR GREASE ORGANIC COMPOUND PAINTS PEST.ICIDES PLATTING WASTES PRETREATMENT SLUDGES �. SOLVENTS 1 THINNERS S Estimated gallons or lbs, per year S 5 e OTHER BAZARDOUS WASTES (SPECIFI) 16, FOR THE ABOVE CHECKED WASTES, DOES YOUR COMPANY PRACTICE: (PLEASE CIRCE.E THE ONE THAT gppLiES) ON 1 AFF SITE STORAGE ON / OFF SITE DISPOSAL 17• BRIEFLY DESCRIBE THE METHOD OF DISPOSAL CIRCLED ABOVE: iA "f ( I \ 18. FOR OFF SITE DISPOSAL PROVIDE THE NAME OF THE HAULER AND THE FACILITY RECENING THE WASTES: 19. HAVE YOU SEEN 22. 23. YES ISSUED A LOCAL, STATE, OR FEDERAL EIrIVIRO�TivIE�1T�.L ��RMIT? NO : IF YES, PLEASE LIST THEM: DO YOU OR WILL YOU HAVE CHEMICAL SROTAGE CONTRAINERS, BINS, OR PONDS AT YOUR FACILITY? YES_ NO IF YES PLEASE ATTACH A DESCRIPTION OF THEIR LOCATION, CONTENTS, SIZE GALLONS, TYPE, AND FREQUENCY, METHID OF CLEANING. INDICATE IF THERE IS BURIED METAL CCli i'ra trrFn c -r-u e -r __ _ -• - --•--_.-....� i nrk v n k- .v I tiV U1C YRUTECTION. DO YOU OR W1LL -1 u U HAVE FLOOR DRAINS IN YOUR MANUFACTURIAiG (MFR) OR NO CHEMICAL S'TQRAGE AREA? YES TF YOU HAVE CHEM.I�AL P3RQA"E CUN I AINERS BINS Y OUR MFR AREA COULD AN ACCIDENTAL THE ON SITE DISPOSAL SYSTEM .I) n PONDS, OR FLOOR DRAINS I SPILL LEAD A I] THE PUBLIC SEWER SYSTEM (THOUGH FLOOR DRAINS) THE CITY STORM DRAINS THE GROUND OTHER (SPECIFY) NIA NOT APPLICABLE NO PASSIBLE DISCHARGE TO ANY M IscHAxGE TO.- Y ES 1 NCS YES /No YES/ NO YES I NO YES / NO, YES / NO i ai i 2!5. Z7. v O YOU HAVE AN ACCIDENTAL SPILL PREVENTION PROGRAM (ASPP) TO PREVENT -'.LLS of CHEMICALS, OR SLUDGE DISCHARES FRONJ ENTERING THE CITY SEWER STEM? _YES _NO -----N/A NO FLOOR DRAINS AND/OR DISCHARGE ONLY DOMESTIC WASTE (IF APPLICABLE PLEASE SUBMIT YOUR ASPP PLAN) DO YOU OR WILL YOU DISCHARGE WASTEWATER (OTHER THEN DOMESTIC WASTE FROM YOU BATHROOMS, TOILETS, and F.CT Tn TxaF anRr ft -1 IF YES, PLEASE ATTACH A DESCRIPTION OF THE DISCHARGE AND THE ONSITE DISPOSAL SYSTEM, IF ANY. ALSO INDICATE THE CONTENTS THAT ARE REMOVED, BY WHOM., AND THE ULTIMATE DISPOSAL SITE. THE CITY WILL BE PROVIDING YOU' WITH FURTHER FORMS TO GATHER DETAILED INFORMATION REGARDING YOUR MANUFACTURING PROCESS, FLOWS, WASTEWATER C14ARACTERISTICS AND WASTEWATER TREATMENT SYSTEMS. ARE ANY PROCESS Cuat�rnFc nn n. ............... __ . _ _ --- --• , �n �.srruv�ivNN PLANNED 1N THE NEXT THREL YEARS? YES_ NO IF YES PLEASE ATTACH A SEPARATE FORM DESCRIBING THE NATURE OF PLANNED CHANGES OR EXPANSIONS. ARE YOU A NEW BUSINESS (NOT OPERATING YET OR PROPOSING TO DISCHARGE) IF YOU PLAN TO DISHCARGE WASTEWATER THE CITY WILL BE PROVIDING YOU WITH ADDTITIONAL FORMS A. ARE YOU: TO COMPLETE AND ADDITIONAL GUIDANCE. *ANEW BUSINESS PLANNING TO OCCUPY AN L•XISTING OANT BUILDING? r E. lel U tI * A NEW BUSINESS PLANNING TO CONSTRUCT ,A NEW BUILDING? YES ✓ NO � HAVE YOU APPLIED FOR A BUILDING PERMIT? YCS ✓ NO *WILL YOU BE CONNECTED TO THE PUBLIC SEWER? YES t/ NO B. IF YOU PLAN ON DISCHARGING PROCESS WASTEWATER., WILL A PRETR' TI3dT SYSTEM BE CONSTRUCTED TO TREATOPOSED DISCHARGE _ I•1� YES0 Y l C. PROVIDE BELOW A COMPLLIANCE SCHEDULE FOR THE APPLICA13LE ITEMS. (BEST ESTIMATE) 1. CONSTRUCTION AND COMPLETION DF THE PHYSICAL STRUCTURE (BUILDING) AND MANUFACTURING LINES; 2. CONSTRUCTION SCHEDULE FOR THE PRETREATMENT SYSTEM SAMPLING MANHOLES AND MONITORING INSTRUIVIE ECT.} NTS (FLOW DIETERS, pH METERS, 3. PROPOSED DATE FOR OPERATION OF MANUFACTURING OPERATION. 7 PROPOSED DATE FOR COMMENCEMENT OF DISCHARGE. PROPOSED DATE FOR DEVELOPMENT OF ASPP ACCIDENTAL SPILL PREVEri'TION PROGRAM IF APPLICABLE. THE PROPOSED SCHEDULE: a. CONSTRUCTION QF FACILITY AND MANUFACTUPJNG LINES. b• CONSTRUCTION QF PRETREATMENT FACILITY A ,SAMPLING MANHOLE AND MONITORING INTRUMENTS COMMENCEMENT AICD COMPLETION DATES.- c. 3ATE5:c. QFERATIONAL DATE: d. DATE OF COMMENCEMENTOF DISCHARGE.- e. DISCHARCxE:e. DATE YOU WILL SUBMIT APP; QUALIMED PROFESSIONAL CERTIFICATION I HEREBY CERTIFY UNDER THE PENALTY OF THE LAW THAT THIS INFORMATION WAS OBTAINED IN ACCORDANCE WITH THE APPLICABLE PROCEDURES AND REQUIREMENTRS AS SPECIFIED IN THE FEDERAL GENERAL PRETREATMENT REGULATIONS AND AMENDMENTS THERETO, AND THE CITY'S SEWER USE ORDINANCE. [ AM AWARE T}IAT THERE IS SIGNIFICANT PENALTIES FOR SUBMITTING FLASE INFORMATION, INCLUDING THE POSSIFILITY OF IMPffiSONMENT. NAME (PR T} SIGNATURE FiP,ST AND ST t TITLE AUTHORIZED REPRESENTATIVE STATEMENT ? '5- � -- / C4 4, / PSE ?441m. c 4 Q S' DATE I CERTIFY UNDER THE PENALTY OP LAW THAT 1 HAVE PERSONALLY EXAMINED AND I AM FAMILIAR WITH THE INFORMATION IN THIS REPORT AND ALL THE ATTACHMENTS THEREIN. FURTHERMORE, BASED ON MY INQUIRY OF THOSE PERSONS IMMEDIATELY REPONSIBLE FOR OBTAINING THE INFORMATION IS TRUE, ACCURATE, AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE PSSIBILITY OF IMPRISONMENT. I FURTHER CERTIFY THAT THE SAMPLING RIESULTS REPORTED ARE REPRESENTATIVE OF NORMAL WORK CYCLES AND EXPECTED POLLUTANT DISCHARGES. ti - NAME (P SIGNATURE FIRST AND LAS' TITLE lim 3�C�-7�cG-2(z�� H -ONE# DATE —X% ' .4 a *NOTE: I I TIllJ UU It'']D I[I lot Ak.- TO THE ACTUAL PaEPARER OF THE REPORT IF DIFFERENT FROM THF ens unor->rr........,..,,�, __ . TE OFF C A AR ERA FiJDICIARY, OR OTHER DULY AUTHOR[ZEDxR�PRESENT ATIV tl I H1 R A E FETA S POERSON IS RESPONSIBLE FOR THE OVERALL OPERATION OF THE FACILITY FROM WHICH THE DISCHARGE ORIGINATES. CITY OF REXBURG'S USE ONLY RECEIVED, DATA DISCLOSURE FORM DATE: INSECTION VISIT (IV) DATE: TYPE OF PERMIT THAT WILL BE ISSUED (WET PERMIT ISSUE DATE- NUMBER OF THE PERMIT ISSUED # STARTED DRAFTING PERMIT, DATE- SIC NUMBER ISSUED IF APPLICABLE # DRAFTING PERMIT COMPLETE, DATE FINAL PERMIT COMPLETE, DATE IF APLICABLE TO FACILITY ALREADY Ih1 OPERATIONS WHEN A GREASE TRAP INSTALLED, DATE: WILL BE Categorical Users: EPA has published specific federal standards tern "Categorical pretreatment standards" Cher twenty-six d�f#`erent sets of regulations. �ndustria� fac��it�es covered by these standards are cornmo � �r� a total "Categorical Users". Facilities not covered under this term are considered as "Non n�Y �er'ned Questions # ], 3 Lists the categorical users under part (b). Ca�tego�ica� Uscrs". Please forward tie completed farms to the address listed below. if You have an uestio at 3.59-3035. Thank you for your cooperation. Y q ns contact: CITY OF REXBURG Plant operator /Pretreatment Coordinator Wastewater Department P.Q. Box 280 .Rexburg, Idaho 8344D ��w of Stege Murphy �•�F-U icr,rxtNtN 2. THE AUTHORIZED tATIVE. REPRF.,qFNVTaT,v� .R., �......,.T..__ TE OFF C A AR ERA FiJDICIARY, OR OTHER DULY AUTHOR[ZEDxR�PRESENT ATIV tl I H1 R A E FETA S POERSON IS RESPONSIBLE FOR THE OVERALL OPERATION OF THE FACILITY FROM WHICH THE DISCHARGE ORIGINATES. CITY OF REXBURG'S USE ONLY RECEIVED, DATA DISCLOSURE FORM DATE: INSECTION VISIT (IV) DATE: TYPE OF PERMIT THAT WILL BE ISSUED (WET PERMIT ISSUE DATE- NUMBER OF THE PERMIT ISSUED # STARTED DRAFTING PERMIT, DATE- SIC NUMBER ISSUED IF APPLICABLE # DRAFTING PERMIT COMPLETE, DATE FINAL PERMIT COMPLETE, DATE IF APLICABLE TO FACILITY ALREADY Ih1 OPERATIONS WHEN A GREASE TRAP INSTALLED, DATE: WILL BE Categorical Users: EPA has published specific federal standards tern "Categorical pretreatment standards" Cher twenty-six d�f#`erent sets of regulations. �ndustria� fac��it�es covered by these standards are cornmo � �r� a total "Categorical Users". Facilities not covered under this term are considered as "Non n�Y �er'ned Questions # ], 3 Lists the categorical users under part (b). Ca�tego�ica� Uscrs". Please forward tie completed farms to the address listed below. if You have an uestio at 3.59-3035. Thank you for your cooperation. Y q ns contact: CITY OF REXBURG Plant operator /Pretreatment Coordinator Wastewater Department P.Q. Box 280 .Rexburg, Idaho 8344D ��w of Stege Murphy