DISTRICT OF COLUMBIAPAGE 1 OF 11
WATER AND SEWER AUTHORITY
DEPARTMENT OF WASTEWATER TREATMENT
Wastewater Discharge Permit Application
Note: Complete and return for compliance with the Federal Clean Water Act
Use “N/A” where requested information was considered but determined not to be applicable to the facility.
Note to Signing Official: In accordance with Title40 of the Code of Federal Regulations Part 403 Section 403.14, information and data provided in this permit application 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 DC Official Code 8-105.09 and 40CFR Part2.
The completed application and all attachments should be mailed within 30 days of receipt to: DC Water and Sewer Authority, Department of Wastewater Treatment, Pretreatment Program Manager, 5000 Overlook Avenue, SW, Washington, D.C. 20032. For questions, call (202)7874177.
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.Signature of Industry Signing Official / Date
Section A - General Information
Business or Agency Name
Facility Address / Mailing Address
(if different from previous)
Total area of facility (inc. grounds, parking lots, & buildings)
Signing Official / Primary Contact
Title / Title
Telephone No. / Telephone No.
Facsimile No. / Facsimile No.
E-mail Address / E-mail Address
Is Business or Agency part of a Corporation? / Yes / No
If “yes”, Name of Corporation and state of Incorporation / Address of Corporate Office
Corporate Officer / Title and Phone
Registered Agent / Title and Phone
Section A - General Information (continued)
Check one: / Existing discharge / If existing, date discharge began
Proposed discharge / If proposed, estimated date of discharge
Other facilities located in the District of Columbia which are owned/operated by the business/agency listed above and also discharge non-domestic wastewater
List of all environmental permits held by the facility-attach extra sheet if needed / Provide Issuing Agency, Type of Permit, Permit No., and Expiration Date
Section B - Product or Service Information
Please check ALL existing and proposed activities, facilities, and plant processes applicable to the above facility address:
Electrical and electronic components manufacturing / Manufacturing (specify): ______/ Repair shop, garage
Electroplating/metal finishing / Medical or Dental / Research
Food or beverage processing / Painting, finishing, stripping / School/educational service
Food or beverage service / Paint or ink formulation / Steam Electric Power Generating
Government - civil / Pesticide formulation/application / Transportation
Government - military / Pharmaceutical manufacturing / Vehicle or equipment cleaning
Groundwater Remediation / Pharmacy / Waste hauler
Laboratory / Photographic processing / Waste combustor
Laundry or Dry Cleaning / Printing / Other (specify): ______
Provide a detailed description of all industrial processes, operations, final products,and/or services
For each product manufactured, identify product type/name, amount, and chemical composition
Attach extra sheets if needed
Provide North American Industry Classification System (NAICS) Code(s) for all processes in descending order of importance / a) / b) / c) / d)
e) / f) / g) / h)
Section B - Product or Service Information (continued)
List chemicals and other materials (both liquid and solid) which are used, processed, or stored in bulk, or are present in quantities greater than 30 gallons-attach extra sheet if needed
Material / Quantity used, processed or stored per year
(indicate units) / Is secondary containment used?
(yes, no, n/a) / Locations where used, processed or stored
(may be indicated on map)
Section C - Plant Operational Information
Number of employees / Number of workdays/week
No. of employees/shift and shift times (if applicable) / 1st shift ______2nd shift ______3rd Shift ______
Is operation subject to daily variation? / Yes / No
Is operation subject to monthly variation? / Yes / No
Is operation subject to seasonal variation? / Yes / No
If “Yes”, describe daily, monthly, and/or seasonal variation
Does operation shut down for vacation, maintenance, or other reasons? / Yes / No
If “Yes,” indicate period when shutdown occurs:______
Section C – Plant Operational Information (continued)
Major process discharges are / Batch / Continuous / Both / ______% Batch / ______% Continuous
Average number of batches per work day: ______
Time and duration of batch discharges over a 24-h period
Time and duration of continuous discharges over a 24-h period
Average daily flowrate in gallons per minute (gpm) / 30 minute peak flowrate in gpm
Average wastewater flow in gallons per day (gpd) / Max flow (gpd)
If applicable, seasonal max wastewater flow (gpd) / During month(s) of:
If applicable, seasonal min wastewater flow (gpd) / During month(s) of:
Are any process changes or expansions planned during the next three (3) years that would alter wastewater volumes or characteristics? / Yes / No
If “Yes”, briefly describe these planned changes and their likely effects on the wastewater volume and characteristics-attach extra sheet if needed
Section D - Sewer Information
Assign a sequential reference number to each sewer connection starting with No.1. Also show location of possible sampling points for these sewers and sampling points for regulated processes by placing a “” next to the reference number.
By reference number, list size, descriptive location and flow of each sewer shown in the drawing for Item D-i. (If more than four, attach extra sheet)
Reference No. / Sewer Size
(inches) / Depth to Manhole
(feet) / Descriptive Location of Sewer Connection
or Discharge Point / Ave. Flow
(gpd)
1.
2.
3.
4.
Section E - Water and Wastewater Information
Water Service Account Number(s)
If water is supplied by landlord, provide name and address:
Name of Landlord:
Street:
City: / Zip Code:
Describe any fresh/make-up water treatment or conditioning processes utilized
Please indicate the quantities of water used by and discharged from the activities indicated below in units of gallons per day. The quantities are to be given for each sewer receiving the discharge. Place a “” on any outfall discharging to a storm drain and give the NPDES Permit Number, if applicable.
Type / Ave. Water / Discharge Quantity by Sewer Referenced in Section D / Disch. to / Total Disch.
Usage/Intake / 1 / 2 / 3 / 4 / Storm Drains
Process/regulated process**
a)
b)
c)
d)
Contained in product / N/A / N/A
Sanitary
Evaporation / N/A / N/A
Boiler
Storm water / N/A
Cooling/uncontam’d water
Septic / N/A / N/A
Plant & Eqpt. Washdown
Irrigation & Lawn Watering
Air Poll. Contr. Liquid Waste
Waste Haulers / N/A / N/A
Other:
Total (refer to D-iii)
* NPDES Permit Number
**List categorical pretreatment regulation applicable to each regulated process – see
Section F - Pretreatment
Is any form of pretreatment currently practiced at the facility? / Yes / No
For all waste streams which are treated before discharge, check the appropriate boxes to indicate the types of pretreatment used at this facility and provide required attachment information.
Grease or oil separation: / Solids separation:
Grease trap (inside) / Centrifuge/cyclone
Grease interceptor (in-ground) / Filtration (specify type/size: ______)
Dissolved air flotation / Grit removal (specify type: ______)
Oil/water separator (specify type: ______) / Screens (specify type/size: ______)
Sand filter / Clarifier/interceptor/settling or sedimentation tank
Other (specify: ______) / Sump
Metals treatment: / Other (specify: ______)
Chemical precipitation / Other:
Filtration (specify type/size: ______) / Flow equalization
Ion exchange / Neutralization, pH adjustment
Silver Recovery Unit (specify type: ______) / Ozonation or chlorination
Other (specify: ______) / Reverse Osmosis
Organics treatment: / Water/wastewater reclamation
Activated carbon / Biological treatment (specify type: ______)
Air stripper/scrubber / Other chemical treatment (specify type: ______)
Other (specify: ______) / Other physical treatment (specify type: ______)
Do you have an Operations and Maintenance manual for the pretreatment system? / Yes / No
Is any form of pretreatment planned for the facility within the next three (3) years? / Yes / No
If “Yes”, describe:
Section G - Characteristics of Discharges
Indicate by placing an “X” in the appropriate box by each listed chemical whether it is “Suspected to be Present,” or “Known to be Present,” in your manufacturing or service activity or generated as a by-product. (Some chemicals listed may be known by other names.)
Item
No. /
Chemical Compound / Suspected
Present / Known
Present / Item
No. /
Chemical Compound / Suspected
Present / Known
Present
asbestos (fibrous) / / / bis (2-chloroethoxyl) methane / /
cyanide (total) / / / bis (2-chloroisopropyl) ether / /
antimony (total) / / / bis (2-ethylhexyl) phthalate / /
arsenic (total) / / / bromodichloromethane / /
beryllium (total) / / / bromoform / /
cadmium (total) / / / bromomethane / /
chromium (total) / / / 4-bromophenyl phenyl ether / /
copper (total) / / / butyl benzyl phthalate / /
lead (total) / / / carbon tetrachloride / /
mercury (total) / / / chlordane / /
nickel (total) / / / 4-chloro-3-methylphenol / /
selenium (total) / / / chlorobenzene / /
silver (total) / / / chloroethane / /
thallium (total) / / / 2-chloroethyl vinyl ether / /
zinc (total) / / / chloroform / /
acenaphthene / / / chloromethane / /
acenaphthylene / / / 2-chloronaphthalene / /
acrolein / / / 2-chlorophenol / /
acrylonitrile / / / 4-chlorophenyl phenyl ether / /
aldrin / / / chrysene / /
anthracene / / / 4,4’-DDD / /
benzene / / / 4,4’-DDE / /
benzidine / / / 4,4’-DDT / /
benzo (a) anthracene / / / dibenzo (a, h) anthracene / /
benzo (a) pyrene / / / dibromochloromethane / /
3,4-benzofluoranthene / / / 1,2-dichlorobenzene / /
benzo (g, h, i) perylene / / / 1,3-dichlorobenzene / /
benzo (k) fluoranthene / / / 1,4-dichlorobenzene / /
-BHC (alpha) / / / 3,3’-dichlorobenzidene / /
-BHC (beta) / / / 1,1-dichloroethane / /
-BHC (delta) / / / 1,2-dichloroethane / /
-BHC (gamma) / / / 1,1-dichloroethene / /
bis (2-chloroethyl) ether / / / 1,2-trans-dichloroethylene / /
Section G - Characteristics of Discharges (continued)
Table continued from previous page.
Item
No. /
Chemical Compound / Suspected
Present / Known
Present / Item
No. /
Chemical Compound / Suspected
Present / Known
Present
2,4-dichlorophenol / / / methylene chloride / /
1,2-dichloropropane / / / naphthalene / /
(cis & trans) 1,3-dichloropropene / / / nitrobenzene / /
dieldrin / / / 2-nitrophenol / /
diethyl phthalate / / / 4-nitrophenol / /
2,4-dimethylphenol / / / N-nitrosodimethylamine / /
dimethyl phthalate / / / N-nitrosodi-n-propylamine / /
di-n-butyl phthalate / / / N-nitrosodiphenylamine / /
di-n-octyl phthalate / / / PCB-1016 / /
4,6-dinitro-o-cresol / / / PCB-1221 / /
2,4-dinitrophenol / / / PCB-1232 / /
2,4-dinitrotoluene / / / PCB-1242 / /
2,6-dinitrotoluene / / / PCB-1248 / /
1,2-diphenylhydrazine / / / PCB-1254 / /
-endosulfan (alpha) / / / PCB-1260 / /
-endosulfan (beta) / / / pentachlorophenol / /
endosulfan sulfate / / / phenathrene / /
endrin / / / phenol / /
endrin aldehyde / / / pyrene / /
ethylbenzene / / / 2,3,7,8-tetrachlorodibenzo-p-dioxin / /
fluoroanthene / / / 1,1,2,2-tetrachloroethane / /
fluorene / / / tetrachloroethylene / /
heptachlor / / / toluene / /
heptachlor epoxide / / / toxaphene / /
hexachlorobenzene / / / 1,2,4-trichlorobenzene / /
hexachlorobutadiene / / / 1,1,1-trichloroethane / /
hexachlorocyclopentadiene / / / 1,1,2-trichloroethane / /
hexachloroethane / / / trichloroethylene / /
indeno (1,2,3-cd) pyrene / / / 2,4,6-trichlorophenol / /
isophorone / / / vinyl chloride / /
Section G - Characteristics of Discharges (continued)
List those items indicated above as being discharged and provide the following information. If their concentration in milligrams per liter (mg/L) is not known, indicate by marking “unknown.”
Item
No. / Parameter/
Chemical Compound / Annual Disch.
(lbs.) / Disch. Conc.
(mg/l) / Item
No. / Parameter/
Chemical Compound / Annual Disch.
(lbs.) / Disch. Conc.
(mg/l)
- / BOD5
- / COD
- / Total Suspended Solids
- / TKN (Nitrogen)
- / Oil & Grease
- / Total Phosphorus
If any wastewater analyses have been performed on the wastewater discharges from your facilities, attach a copy of the most recent data to this application, if not previously submitted to DC Water. Include laboratory report and chain of custody form.
Yes, the required laboratory data is attached. / No wastewater analyses have been performed.
No, laboratory data has previously been submitted.
List the temperature and pH range of your discharge for each discharging point. (Attach additional sheets, if necessary.)
Reference No. / TemperatureRange / pH Range
(refer to D-iii) / Low / Average / High / Low / Average / High
1.
2.
3.
4.
How was this data collected?
Section H - Non-discharged Wastes
Are any waste liquids or sludges generated and NOT disposed of in the sewer system? / Yes / No
If “No,” skip the rest of Section H. If “Yes,” these may best be described and quantified as:
Waste / Estimated Quantity
(lbs or gal/year) / Disposal Method*
(use codes below) / Waste / Estimated Quantity
(lbs or gal/year) / Disposal Method
(use codes below)
Waste solvent / Paints
Waste product / Acids & alkalis
Oil / Plating wastes
Grease / Pesticides
Pretreatment sludge / Other (specify)
Inks/dyes
Thinner
Heavy metals
Organic compounds
Codes:
a)Waste is collected for off-site disposal
b)Waste is placed with trash for disposal.
c)Waste is treated or recycled/reused on-site
If waste haulers are used, provide their name(s), address(es),EPA number(s), and type of waste removed (attach extra sheet, if needed):
Hauler A:
Hauler B:
Hauler C:
Hauler D:
Do any of your non-discharged wastes require an EPA Hazardous Waste Generator ID? / Yes / No
If “Yes,” provide your ID number and type of permit (large quantity generator, small quantity generator, or conditionally exempt small quantity generator).
Are you required to havea SPCC plan (Spill Prevention Control and Countermeasure)? / Yes / No
Provide a list of other environmental plans prepared for your facility:
Attachments
- REQUIRED - Attach a scaled drawing of your plant site showing the location of all building sewer connections, building drains, process waste sewers, monitoring and pretreatment facilities, buildings, property lines, adjacent streets and sewers, and industrial process facilities.
- REQUIRED - Attach a drawing/flow diagram/description for each existing or planned pretreatment unit/system. Include location of each unit andwhich sewer it discharges to, identify each wastewater generating process going to the unit, and provide process equipment (manufacturer, model, and capacity in gpm), operational set points and alarms, list of treatment chemicals used, by-products, by-product disposal method, and wastewater and by-product volumes and concentrations (if known).
- REQUIRED - Process Flow Diagram – Required for all categorical industrial user regulated processes. Show average daily flow of water, material, and chemicals used in each process, flow to treatment systems, by-products and their disposal method, and final products.
- OPTIONAL - Request for monitoring waiver (or a renewal of an approved monitoring waiver) for a pollutant neither present nor expected to be present in the discharge based on 21 DCMR 1508.11.
- OPTIONAL – Request for submitted information to be classified as “confidential business information” if such information and data would disclose trade secrets or secret processes, in accordance with 21 DCMR 1512. “Confidential Business Information” must be stamped on each page containing such information.
FORM PLD-002: Rev. 07/01/16