Commercial Wastewater ... - Water & Utilities
Arlington County Industrial/Commercial Wastewater User Survey Please mail, fax, or e-mail this questionnaire to the Pretreatment Program Coordinator at the address below. If you have any questions or need assistance, please contact our office. NOTE: IF HOME-BASED BUSINESS ONLY, CHECK HERE , THEN COMPLETE CONTACT INFORMATION BELOW; SECTION 1; AND SIGN CERTIFICATION STATEMENT ON REVERSE SIDE.
Water Pollution Control Bureau Pretreatment Program Coordinator 3402 S. Glebe Road Arlington, VA 22202 Phone (703) 228-6881, Fax (703) 228-6875 e-mail [email protected]
Business Name
Phone:_
Physical Address Mailing Address Person to contact regarding this survey
Phone:
Property Owner
Phone:
Business Location 1.
Business Activities: Electroplating Flammables, explosives Food or beverage services Dry cleaning Government-civil Government-military Laboratory Laundry, cleaning Machine shop
Metal Finishing Medical or dental care Office(s) Painting, finishing Paint or ink formulation Photographic processing Manufacturing Plastics processing Printing/binding
Powder Coating Research Residential Retail Trade Vehicle/equipment services Warehousing Wholesale trade Other, specify:_
(a) List SIC/NAICS codes: _______________________________________________________________ 2.
Type of Business: (If “Other,” explain)
Industrial
(a) Total number of employees: 3.
Sewer is connected to: (check one) (If “Other,” explain)
Commercial
0-5
6-15
Manufacturing
16-50
County Sewer System
51-100
Restaurant
Other
101-300
300+
Private Septic Tank
Other
4.
Provide a brief description of all operations at this facility, including primary products or services:
5.
Is a wastewater pretreatment device utilized prior to discharge to the sewer? (This includes grease interceptors, grease traps, hair traps, silver recovery, acid neutralization, cyanide destruction, metals precipitation etc.) Yes No (If “yes,” specify, include size/capacity of traps/interceptors and specifications of all treatment devices).
6.
Estimate how much water the business will use for all activities during a typical working day: less than 1,000 gallons
1,000 to 5,000 gallons
5,000 to 25,000 gallons
7.
Will water be used for any process other than sanitary waste? (If “Yes,” explain process(es) and estimated volume per day)
8.
Will the facility generate or store any hazardous material, petroleum products, solvents, or chemicals? Yes
9.
No
Yes
more than 25,000 gallons
No
(If “Yes,” list)
Will any waste be hauled off-site:
Yes
No
If yes, please indicate the type of waste: Acid/Alkalis Pesticides (If “Other,” explain)
Solvents Other
Heavy Metals
Oils & Grease
Radioactive
Paint
10. List any environmental permits managed by the facility: _________________________________________________________________________________________ _________________________________________________________________________________________ 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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Printed Name:
Title:
Signature:
Date:
In accordance with 40 CFR 403.8(f)(2) of the Code of Federal Regulations, the Virginia Administrative Code 9 VAC 25-31-730, and the Arlington County Code Chapter 26, the County is required to identify, locate, and evaluate industrial and commercial users that may be subject to the Arlington County Pretreatment Program. This evaluation is conducted to help prevent the discharge of wastewater that may: Damage components of the wastewater collection system; Expose personnel to health or safety hazards; Cause pass-through of pollutants at the Wastewater Treatment Plant, or interference with Plant processes; or Contaminate biosolids produced from the Plant. In accordance with the above regulation and Codes, your business is required to complete and submit the above Industrial User Survey. Failure to submit will automatically result in a follow-up facility inspection.
Water Pollution Control Bureau Pretreatment Program Coordinator 3402 S. Glebe Road Arlington, VA 22202 Phone (703) 228-6881, Fax (703) 228-6875 e-mail [email protected]
Business Name
Phone:_
Physical Address Mailing Address Person to contact regarding this survey
Phone:
Property Owner
Phone:
Business Location 1.
Business Activities: Electroplating Flammables, explosives Food or beverage services Dry cleaning Government-civil Government-military Laboratory Laundry, cleaning Machine shop
Metal Finishing Medical or dental care Office(s) Painting, finishing Paint or ink formulation Photographic processing Manufacturing Plastics processing Printing/binding
Powder Coating Research Residential Retail Trade Vehicle/equipment services Warehousing Wholesale trade Other, specify:_
(a) List SIC/NAICS codes: _______________________________________________________________ 2.
Type of Business: (If “Other,” explain)
Industrial
(a) Total number of employees: 3.
Sewer is connected to: (check one) (If “Other,” explain)
Commercial
0-5
6-15
Manufacturing
16-50
County Sewer System
51-100
Restaurant
Other
101-300
300+
Private Septic Tank
Other
4.
Provide a brief description of all operations at this facility, including primary products or services:
5.
Is a wastewater pretreatment device utilized prior to discharge to the sewer? (This includes grease interceptors, grease traps, hair traps, silver recovery, acid neutralization, cyanide destruction, metals precipitation etc.) Yes No (If “yes,” specify, include size/capacity of traps/interceptors and specifications of all treatment devices).
6.
Estimate how much water the business will use for all activities during a typical working day: less than 1,000 gallons
1,000 to 5,000 gallons
5,000 to 25,000 gallons
7.
Will water be used for any process other than sanitary waste? (If “Yes,” explain process(es) and estimated volume per day)
8.
Will the facility generate or store any hazardous material, petroleum products, solvents, or chemicals? Yes
9.
No
Yes
more than 25,000 gallons
No
(If “Yes,” list)
Will any waste be hauled off-site:
Yes
No
If yes, please indicate the type of waste: Acid/Alkalis Pesticides (If “Other,” explain)
Solvents Other
Heavy Metals
Oils & Grease
Radioactive
Paint
10. List any environmental permits managed by the facility: _________________________________________________________________________________________ _________________________________________________________________________________________ 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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Printed Name:
Title:
Signature:
Date:
In accordance with 40 CFR 403.8(f)(2) of the Code of Federal Regulations, the Virginia Administrative Code 9 VAC 25-31-730, and the Arlington County Code Chapter 26, the County is required to identify, locate, and evaluate industrial and commercial users that may be subject to the Arlington County Pretreatment Program. This evaluation is conducted to help prevent the discharge of wastewater that may: Damage components of the wastewater collection system; Expose personnel to health or safety hazards; Cause pass-through of pollutants at the Wastewater Treatment Plant, or interference with Plant processes; or Contaminate biosolids produced from the Plant. In accordance with the above regulation and Codes, your business is required to complete and submit the above Industrial User Survey. Failure to submit will automatically result in a follow-up facility inspection.
