City of Toledo

CITY OF TOLEDO

DIVISION OF ENVIRONMENTAL SERVICES

WATER RESOURCES SECTION

BASELINE MONITORING REPORT

(One Form Required Per Facility)

SECTION A. GENERAL INFORMATION

1.Company Name ______

______

2.Mailing Address – PO Box or Street Address______

City______Zip______

3.Facility Address – Street Address______

City______Zip______

4.Provide the name of the person who completed this report.

Name______

Title______Phone______

5.Provide the name of a person to contact regarding information contained in this report.

Name______

Title______Phone______

______

SECTION B. PRODUCT OR SERVICE INFORMATION

1.Brief description of manufacturing or service activity at this facility.

______

______Primary SIC/NAICS Code______

2.List each product and daily rate of production indicating appropriate units. Include any by-products which can be used or sold, if applicable.

PRODUCT / DAILY RATE OF PRODUCTION
Average / Maximum

3.List type and amount of raw materials utilized indicating appropriate units.

RAW MATERIAL / AMOUNT USED PER DAY
Average / Maximum

SECTION C. SITE AND FLOOR PLAN

Provide a general site and floor plan, which shows the physical location of the building to the property lines, streets, alleys and other topographic features. Also, show the layout of the plant by major areas of activities such as processes, chemical or material storage, maintenance, and office areas. Show all sewers and service connections and assign a number to each sewer. Show all inspection manholes and sampling chambers where process wastes can be collected. Indicate any watercourse or other drainage systems, which receive any plant discharge.

______

SECTION D. FACILITY OPERATIONAL CHARACTERISTICS

1.a)Do scheduled shut-downs occur? Yes______No______

b)If yes, list time period(s)______

2.a)Is production seasonal?Yes______No______

b)If yes, indicate period(s) of maximum production and products.

______

3.Circle days per week of operation. 4 5 6 7 Other-Specify______

4.Circle hours per day of operation. 8 10 16 24 Other Specify______

5.Shift information:

1st / 2nd / 3rd
Starting time
# Employees per shift / Total of all employees

______

SECTION E. WATER USE INFORMATION

1.Indicate water use and discharge information.

Type of Use / USE / Method of Discharge
Yes / No / Storm / Sanitary / Other / None / GPD
Process Water
Cooling Water, Contact
Cooling Water, Noncontact
Cooling Tower/Blowdown
Boiler Water Blowdown
Air Pollution Control Unit
Contained in Product
Sanitary Wastes
Other (Describe Below)

2.List Average Daily Plant Water Use(GPD):______

3.a)Are other sources of water used(well, river, etc.)? Yes_____ No______

b)If yes, list source and usage: Source ______Usage ______Gal/Day

4.a)Does usage vary widely during the production day? Yes_____ No_____

b)Indicate the maximum peak use:Time______GPD______

5.a)Are corrosion or biological inhibiting chemicals added to facility water systems which are

discharged to the sewer?Yes______No______

b)If yes, list chemicals:______

______

6.a)Are raw water treatment processes employed?

Yes______No______

b)If yes, list process(es) and method of residue disposal:______

______

SECTION F. WASTEWATER INFORMATION

1.a)Sewer bill is based on: Metered Water Use______or Sewer Meter______

b)If a sewer meter is employed, list manufacturer and describe method of operation: ______

______

2.Is sanitary waste discharged separately from process waste? Yes_____No_____

3.a) Are all of your liquid wastes discharged to the sanitary sewer system?

Yes_____ No______

b)If no, describe any other liquid disposal method(s).______

______

c) If a National Pollutant Discharge Elimination System (NPDES) Permit has been issued for this facility, list permit number:______

4.List any other environmental permits held by this facility and show permit number and expiration date:______

______

5.Describe each process, which discharges wastewater to a building sewer and use applicable SIC/NAICS Code.

Process / Process Description / SIC/NAICS Code
1
2
3
4
5

6.For each process listed above (5), indicate the characteristic of the wastewater, the sewer number (identified in Section C), the type of discharge, and the metered or estimated average and maximum daily discharges.

Process / Wastewater / Sewer / Type / Daily Discharge
Characteristics / No. / Batch / Cont / Ave. / Max(GPD)
1
2
3
4
5

SECTION G. PRETREATMENT

1.a)Are wastewaters pretreated prior to discharge to the sanitary sewer system?

Yes_____No_____

b)If yes, indicate which system(s) are used:

( ) Air Flotation

( ) Chlorination

( ) Flow Equalization

( ) Grease Trap

( ) Ion Exchange

( ) Reverse Osmosis

( ) Sedimentation

( ) Chemical Precipitation

( ) Filtration

( ) Grease or Oil Separation

( ) Grit Removal

( ) Neutralization/pH Control

( ) Screening

( ) Solvent Separation

( ) Biological Treatment, type

( ) Rainwater diversion or storage, type

( ) Other Chemical Treatment, type

( ) Other Physical Treatment, type

( ) Other, type

2.Describe any residue treatment prior to disposal:

3.Indicate quantity and method of disposal:

4.Is the residue considered a hazardous waste as defined by the Resource Conservation and Recovery Act (RCRA)?

Yes_____No_____Unknown_____

5.Are air pollution control devices employed?Yes_____No_____

a)If yes, indicate the control device(s), quantity, and method of residue disposal:

b)Is the residue considered a hazardous waste under RCRA?

Yes_____No_____Unknown_____

c)If yes, the residue is a hazardous waste because it is

Listed_____Characteristic_____

SECTION H. CHEMICAL USE INFORMATION

1.List chemicals, which are stored in bulk quantities (1000 gallons or greater). Include fuel oil used for building heat and process operation.

Chemical Name

______

Amount Stored

______

2.Does facility have a SPCC Plan? Yes____No_____ None Required_____

Does facility have a Slug Control Plan?Yes____ No_____ None Required_____

a)Describe any spill control methods or facilities.

______

SECTIONI. WASTEWATER DISCHARGE CHARACTERISTICS

1.Refer to Table 1 to generally characterize your wastewater.

2.Refer to Table 2 to indicate any Priority Pollutants used and discharged from your facility.

3.Provide a laboratory analysis for the substances indicated as being discharged in Table 2 and for all parameters in Table 3. Include a diagram showing sampling location(s). (These may be indicated on the site and floor plan-Section C.).

______

SECTION J. SIGNATURES

I have personally examined and am familiar with the information submitted in this form and attachments. Based upon on my own observations and inquire of those individuals immediately responsible for obtaining information reported herein, I believe that the submitted information is true, accurate and complete.

______

Signature of OfficialTitleDate

I certify that, to the best of my knowledge, the wastewater discharged from this facility is in compliance with the City of Toledo Sewer Use Ordinance as defined in Sections 930.03, 930.04, and 930.05.

______

Signature of OfficialTitleDate

The discharge from this facility is not in compliance with limits defined in the City of Toledo Sewer Use Ordinance, Sections 930.03, 930.04, and 930.05. Therefore, we are providing with this form, compliance schedule as required by Section 930.13(b) of the City of Toledo Sewer Use Ordinance.

______

Signature of OfficialTitleDate

TABLE 1

GENERAL WASTEWATER CHARACTERISTICS

Check the space(s), which indicate substances contained in your wastewater.

1.Acids and acidic wastes___16.Alcohols ____

2.Alkali and caustic wastes___17.Ethers____

3.Pickling wastes___18.Aldehydes, ketones____

4.Metal Cleaning and

preparation wastes___19. Organic Acids____

5.Metal finishing wastes___20.Soaps, Surfactants,

Detergents____

6. Electroplating

& other wastes___21.Oils____

7.Paints & Pigments___22.Fats, grease____

8.Pesticides & Herbicides___23.Benzene & benzene

derivatives____

9.Inks & Printing Wastes___24.Chlorinated Organic

Compounds____

10.Dyes, coloring agents___25.Brominated Organic

Compounds____

11.Organic Solvents, thinners___26.Hot wastes____

12. Latex wastes___27.Radioactive wastes____

13.Resins, monomers___28.Photographic wastes____

14.Waxes___29. Sanitary Waste ONLY____

15.Phenol containing wastes___30. Other wastes ____

TABLE 2

PRIORITY POLLUTANT INFORMATION

Describe: For each compound listed below, place an "X" in the space which most appropriately characterizes the compounds' use and discharge from this facility. The compounds, which have an asterisk (*) are known by other names as indicated in Appendix B of the instructions.

Item / Used / Discharged / Item / Used / Discharged
# / Chemical Compound / Yes / No / Yes / No / # / Chemical Compound / Yes / No / Yes / No
Intermit. / Cont. / Intermit. / Cont.
1 / Asbestos (fibrous) / 66 / 1,2-dichloroethane*
2 / Cyanide (total) / 67 / 1,1-dichloroethene*
3 / Antimony (total) / 68 / trans-1,2-dichloroethene*
4 / Arsenic (total) / 69 / 2,4-dichlorophenol
5 / Beryllium (total) / 70 / 1,2-dichloropropane*
6 / Cadmium (total) / 71 / cis/trans-1,3-dichloropropene*
7 / Chromium (total) / 72 / dieldrin
8 / Copper (total) / 73 / diethylphthalate*
9 / Lead (total) / 74 / 2,4-dimethylphenol*
10 / Mercury (total) / 75 / dimethylphthalate
11 / Nickel (total) / 76 / di-n-butyl phthalate
12 / Selenium (total) / 77 / di-n-octyl phthalate*
13 / Silver (total) / 78 / 4,6-dinitro-2-methylphenol*
14 / Thallium (total) / 79 / 2,4-dinitrophenol
15 / Zinc (total) / 80 / 2,4-dinitortoluene
Item / Used / Discharged / Item / Used / Discharged
# / Chemical Compound / Yes / No / Yes / No / # / Chemical Compound / Yes / No / Yes / No
Intermit. / Cont. / Intermit. / Cont.
16 / Acenaphthene / 81 / 2,6-dinitrotoluene
17 / Acenaphthylene / 82 / 1,2-diphenylhydrazine*
18 / Acrolein / 83 / endosulfan I*
19 / Acrylonitrile / 84 / endosulfan II*
20 / Aldrin / 85 / endosulfan sulfate
21 / Anthracene / 86 / endrin
22 / Benzene / 87 / endrin aldehyde
23 / Benzidine / 88 / ethylbenzene
24 / Benzo-(a)-anthracene* / 89 / fluoranthene
25 / Benzo-(a)-pyrene* / 90 / fluorene*
26 / Benzo-(b)-fluoranthene / 91 / heptachlor
27 / Benzo(g,h,i)perylene* / 92 / heptachlor epoxide
28 / Benzo-(k)-fluoranthene* / 93 / hexachlorobenzene*
29 / a-BHC (alpha) / 94 / hexachlorobutadiene
30 / b-BHC (beta) / 95 / hexachlorocyclopentadiene *
31 / d-BHC (delta) / 96 / hexachloroethane*
32 / g-BHC (gamma)* / 97 / indeno-(1,3,3-cd) pyrene*
33 / bis(2-chloroethyl)ether* / 98 / isophorone*
34 / bis(2-chloroethoxy) methane / 99 / methylene chloride*
Item / Used / Discharged / Item / Used / Discharged
# / Chemical Compound / Yes / No / Yes / No / # / Chemical Compound / Yes / No / Yes / No
Intermit. / Cont. / Intermit. / Cont.
35 / bis(2-chloroisopropyl) ether* / 100. / naphthalene
36 / bis(chloromethyl)ether* / 101 / nitrobenzene
37 / bis(2-ethylhexyl) phthalate* / 102 / 2-nitrophenol*
38 / bromodichloromethane* / 103 / 4-nitrophenol*
39 / bromoform* / 104 / N-nitrosodimethylamine *
40 / bromomethane* / 105 / N-nitrosodi-n-propylamine *
41 / 4-bromophenylphenyl ether / 106 / N-nitrosodiphenylamine*
42 / butylbenzyl phthalate / 107 / PCB-1016*
43 / carbon tetrachloride* / 108 / PCB-1221*
44 / chlordane / 109 / PCB-1232*
45 / 4-chloro-3-methylphenol* / 110 / PCB-1242*
46 / chlorobenzene / 111 / PCB-1248*
47 / chloroethane* / 112 / PCB-1254*
48 / 2-chloroethylvinyl ether / 113 / PCB-1260*
49 / chloroform* / 114 / pentachlorphenol
50 / chloromethane* / 115 / phenanthrene
51 / 2-chloronaphthalene / 116 / phenol
52 / 2-chlorophenol* / 117 / pyrene
53 / 4-chlorophenylphenyl ether / 118 / 2,3,7,8-tetrachlorodibenzo-p-dioxin*
54 / chrysene* / 119 / 1,1,2,2-tetrachloroethane *
55 / 4,4'-DDD* / 120 / tetrachloroethene*
56 / 4,4'-DDE* / 121 / toluene*
57 / 4,4'-DDT* / 122 / toxaphene
Item / Used / Discharged / Item / Used / Discharged
# / Chemical Compound / Yes / No / Yes / No / # / Chemical Compound / Yes / No / Yes / No
Intermit. / Cont. / Intermit. / Cont.
58 / dibenzo(a,h)anthracene* / 123 / 1,2,4-trichlorobenzene
59 / dibromochloromethane* / 124 / 1,1,1-trichloroethane*
60 / 1,2-dichlorobenzene* / 125 / 1,1,2-trichloroethane*
61 / 1,3-dichlorobenzene* / 126 / trichloroethane*
62 / 1,4-dichlorobenzene* / 127 / trichlorofluoromethane*
63 / 3,3'-dichlorobenzidine / 128 / 2,4,6-trichlorophenol
64 / dichlorodifluoromethane* / 129 / vinyl chloride*
65 / 1,1'dichloroethane*

PRIORITY POLLUTANTS FROM TABLE 2

In the table below, please list and analyze for any priority pollutant(s) in Table 2

that you have indicated are discharged in your wastewater. It is not necessary

to analyze and report a pollutant here if it is already shown in Table 3.

PARAMETER / TEST RESULTS
No. / NAME / UNITS

TABLE 3

DISCHARGERS COMPLIANCE REPORT

All samples analyzed for this report should be taken from the designated Local Limit sampling location.

(Industry Name) / Toledo Discharge Standards / Test Results / Compliance
Parameter / Local Limit
(mg/L) / Daily Maximum (mg/L) / Yes / No
Arsenic
Cadmium
Copper
Hexavalent Chromium
Lead
Mercury / 0.0002*
Nickel
Silver
Zinc
Cyanide
pH / 5 – 12
Total Petroleum Hydrocarbons (TPH) / 250
Oil & Grease / 250
Total Toxic Organics (TTO) / 2.10
Xylene / 0.41
Total Phenols
Sulfide
Selenium
Total Chromium
Biological Oxygen Demand (BOD) / 300**
Chemical Oxygen Demand (COD) / 600**
Suspended Solids (SS) / 400**
Phosphorus (P) / 15**

*Action threshold amount – enforced by BMPs **Surcharge threshold amounts