Wastewater Treatment Plant(S) Included in Program: Npdes Permit Number(S)

DATE:

SEWER AUTHORITY NAME:

PERIOD COVERED BY REPORT:TO:

WASTEWATER TREATMENT PLANT(S) INCLUDED IN PROGRAM: NPDES PERMIT NUMBER(S):

CONTACT PERSON:

NAME:

TITLE:

MAILING ADDRESS:

ZIP:

TELEPHONE:( ) EMAIL:

I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED AND AM FAMILIAR WITH THE INFRORMATION IN THIS REPORT AND ALL ATTACHMENTS. BASED ON MY INQUIRY OF THOSE PERSONS IMEDIATELY RESPONSIBLE FOR OBTAINING THE INFORMATION CONTAINED IN THE REPORT, I BELIEVE THAT THE INFORMATION IS TRUE, ACCURATE AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT.

SIGNATURE OF OFFICIALDATE

TITLE

Mail completed reports to:

Ohio EPA, DSW

Pretreatment Unit

P.O. Box 1049, Columbus, Ohio 43216-1049

PRETREATMENT PERFORMANCE SUMMARY

POTW:

NPDES PERMIT NO.:

REPORTING PERIOD: TO

TOTAL SIGNIFICANT INDUSTRIAL USERS (SIU’s):0

TOTAL CATEGORICAL INDUSTRIAL USERS (CIU’s):0

TOTAL SIGNIFICANT NON-CATEGORICAL INDUSTRIAL USERS:0

COMPLIANCE MONITORING PROGRAM

# OF EFFECTIVE CONTROL DOCUMENTS0

# OF SIU’s INSPECTED0

# OF SIU’s SAMPLED0

SIGNIFICANT NONCOMPLIANCE ASSESSMENT (SNC)

# OF SIU’s IN SNC (Categorical/Non-Categorical)0/0

# OF SIU”s IN SNC FOR SAMPLING VIOLATIONS0

# OF SIU’s IN SNC FOR REPORTING VIOLATIONS0

# OF SIU’s IN SNC FOR COMPLIANCE SCHEDULE VIOLATIONS0

# OF NON SIGNIFICANT IU’s IN SNC 0

ENFORCEMENT ACTIVITY

# OF SHOW-CAUSE HEARINGS0

# OF COMPLIANCE SCHEDULES ISSUED0

# OF ADMINISTRATIVE ORDERS ISSUED0

# OF CIVIL SUITS FILED0

# OF CRIMINAL SUITS FILED0

AMOUNT OF PENALTIES COLLECTED (Total dollars/# IU’s assessed)0/0

# OF FACILITIES IN SNC PUBLISHED (Attach newspaper list)0

GENERAL MONITORING INFORMATION

POTW: PERIOD COVERED: TO

IU CLASSIFICATION or /

POTW INDUSTRIAL USER MONITORING

/ INDUSTRIAL USER SELF-MONITORING

GENERAL PERMIT NAME

/ INSPECTION FREQ / SAMPLING FREQ /

SAMPLING FREQ

/ REPORTING FREQ

EXCEPTIONS TO STANDARD MONITORING

POTW: PERIOD COVERED: TO

FACILITY NAME & ADDRESS / NONSIGNIFICANT CIU? / MID TIER CIU? / CATEGORICAL MONITORING WAIVER? / LOCAL LIMIT
MONITORING
WAIVER?

Form 4117, 4221 (9/16)AR-1

INDUSTRIAL USER INVENTORY AND MONITORING

POTW: PERIOD COVERED: TO

POTW IU MONITORING / IU SELF-MONITORING
FACILITY NAME & ADDRESS / LOCAL CLASSIFICATION
(SIU, CIU, etc.) / APPLICABLE STANDARDS
(40 CFR 4XX or local limits) / # OF INSPECTIONS / # SAMPLE EVENTS / # SAMPLE EVENTS / REPORTING FREQUENCY

Form 4117, 4221 (9/16)AR-1

INDUSTRIAL INVENTORY MODIFICATIONS

POTW: DATE: PAGE ____ OF ____

FACILITY NAME & / ADD, / REASON FOR CHANGE OR DELETION / IF ADDITION OR SIGNIFICANT CHANGE:
ADDRESS/
CONTACT PERSON / CHANGE,
DELETE / PROCESS DESCRIPTION / LOCAL CLASSIFICATION / FLOW RATE / POLLUTANTS / APPLICABLE STANDARDS

Form 4117, 4221 (9/16)AR-1

UPSETS, INTERFERENCE AND PASS-THROUGH INCIDENTS

POTW: PERIOD COVERED: to PAGE _____ OF ______

TYPE OF INCIDENT / DATE / EXPLANATION/REASON / CORRECTIVE ACTION(S) TAKEN

Form 4117, 4221 (9/16)AR-1

POTW:______

LABORATORY: ______

SAMPLING:DATE TIME

Start Stop

INFLUENT______

EFFLUENT______

SLUDGE 1______

SLUDGE 2______

SAMPLING LOCATION:

INFLUENT______

EFFLUENT______

SLUDGE 1______

SLUDGE 2______

HEAVY METALS:______

______

ORGANICS:

VOLATILES:______

______

EXTRACTABLES:______

______

OTHER:______

______

PERCENT SLUDGE SOLIDS: SLUDGE 1______SLUDGE 2 ______

COMMENTS:______

______

______

______

______

______

______

POTW PRETREATMENT CONTACT:

______

Name and Title (please print)

______

SignatureDate

CAS # / POLLUTANT / INFLUENT / EFFLUENT / SLUDGE 1 / SLUDGE 2
Ug/L / Ug/L / Mg/Kg Dry / Mg/Kg Dry
Heavy Metals (14)
7440-36-0 / Antimony / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-38-2 / Arsenic / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-41-7 / Beryllium / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-43-9 / Cadmium / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-47-3 / Chromium / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-50-8 / Copper / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7439-92-1 / Lead / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7439-97-6 / Mercury / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7439-98-7 / Molybdenum / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-02-0 / Nickel / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7782-49-2 / Selenium / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-22-4 / Silver / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-28-0 / Thallium / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7440-66-6 / Zinc / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
Volatiles (28)
107-02-08 / Acrolein / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
107-13-1 / Acrylonitrile / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
71-43-2 / Benzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
75-25-2 / Bromoform / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
56-23-5 / Carbon Tetrachloride / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
108-90-7 / Chlorobenzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
124-48-1 / Chlorodibromomethane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
75-00-3 / Chlorothane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
110-75-8 / 2-Chloroethylvinyl Ether / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
67-66-3 / Chloroform / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
75-27-4 / Dichlorobromomethane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
75-34-3 / 1,1-Dichloroethane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
107-06-2 / 1,2-Dichloroethane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
75-35-4 / 1,1-Dichloroethylene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
78-87-5 / 1,2-Dichloropropane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
542-75-6 / 1,3-Dichloropropylene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
100-41-4 / Ethylbenzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
74-83-9 / Methyl Bromide / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
74-87-3 / Methyl Chloride / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
75-09-2 / Methylene Chloride / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
79-34-5 / 1,1,2,2-Tetrachloroethane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
027-18-4 / Tetrachloroethylene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
108-88-3 / Toluene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
156-60-5 / 1,2-Trans-Dichloroethylene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
71-55-6 / 1,1,1-Trichloroethane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
79-00-5 / 1,1,2-Trichloroethane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
79-01-6 / Trichloroethylene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
75-01-4 / Vinyl Chloride / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
CAS # / POLLUTANT / INFLUENT / EFFLUENT / SLUDGE 1 / SLUDGE 2
Ug/L / Ug/L / Mg/Kg Dry / Mg/Kg Dry
Base Neutrals (46)
83-32-9 / Acenaphthene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
208-96-8 / Acenaphthylene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
120-12-7 / Anthracene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
92-87-5 / Benzidine / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
56-55-3 / Benzo (A) Anthracene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
50-32-8 / Benzo (A) Pyrene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
205-99-2 / 3,4-Benzofluoranthene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
191-24-2 / Benzo (GHI) Perylene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
207-08-9 / Benzo (K) Flouranthene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
111-91-1 / Bis (2-Chloroethoxy) Methane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
111-44-4 / Bis (2-Chloroethyl) Ether / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
108-60-1 / Bis (2-Chloroisophropyl) Ether / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
117-81-7 / Bis (2-Ethylhexyl) Phthalate / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
101-55-3 / 4-Bromophenylphenyl Ether / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
85-68-7 / Butyl Benzylphthalate / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
91-58-7 / 2-Chloronapthalene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7005-72-3 / 4-Chlorophenyl Phenyl Ether / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
218-01-9 / Chrysene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
53-70-3 / Dibenzo (A,H) Anthracene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
95-50-1 / 1,2-Dichlorobenzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
541-73-1 / 1,3-Dichlorobenzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
106-46-7 / 1,4-Dichlorobenzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
91-94-1 / 3,3-Dichlorobenzidine / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
84-66-2 / Diethyl Phthlate / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
131-11-3 / Dimethyl Phthalate / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
84-74-2 / Di-N-Butyl Phthalate / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
121-14-2 / 2,4-Dinitrotouluene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
606-20-2 / 2,6-Dinitrotouluene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
117-84-0 / Di-N-Octyl Phthalate / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
122-66-7 / 1,2-Diphenylyydrazine / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
206-44-0 / Fluoranthene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
86-73-7 / Fluorene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
118-74-1 / Hexachlorobenzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
87-68-3 / Hexachlorobutadiene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
77-47-4 / Hexachlorocyclopentadiene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
67-72-1 / Hexachloroethane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
193-39-5 / Indeno (1,2,3-CD) Pyrene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
78-59-1 / Isophorone / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
91-20-3 / Naphthalene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
98-95-3 / Nitrobenzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
62-75-9 / N-Nitrosodimethylamine / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
621-64-7 / N-Nitrosodi-N-Propylamine / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
86-30-6 / N-Nitrosodiphenylamine / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
85-01-8 / Phenanthrene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
129-00-0 / Pyrene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
120-82-1 / 1,2,4-Trichlorobenzene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
95-57-8 / 2-Chlorophenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
120-83-2 / 2,4-Dichlorophenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
105-67-9 / 2,4-Dimethylphenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
CAS # / POLLUTANT / INFLUENT / EFFLUENT / SLUDGE 1 / SLUDGE 2
Ug/L / Ug/L / Mg/Kg Dry / Mg/Kg Dry
534-52-1 / 4,6-Dinitro-O-Cresol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
51-28-5 / 2,4-Dinitrophenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
88-75-5 / 2-Nitrophenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
100-02-7 / 4-Nitrophenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
59-50-7 / P-Chloro-M-Cresol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
87-86-5 / Pentachlorophenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
108-95-2 / Phenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
88-06-2 / 2,4,6-Trichlorophenol / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
Pesticides (26)
309-00-2 / Aldrin / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
319-84-6 / Alpha-BHC / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
319-85-7 / Beta-BHC / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
319-86-8 / Delta-BHC / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
58-89-9 / Gamma-BHC / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
57-74-9 / Chlordane / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
50-29-3 / 4,4-DDT / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
72-55-9 / 4,4-DDE / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
72-54-8 / 4,4-DDD / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
60-57-1 / Dieldrin / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
959-98-8 / Alpha Endosulfan / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
33213-65-9 / Beta Endosulfan / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
1031-07-08 / Endosulfan Sulfate / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
72-20-8 / Endrin / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
7421-93-4 / Endrin Aldehyde / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
76-44-8 / Heptachlor / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
1024-57-3 / Heptachlor Epoxide / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
53469-21-9 / PCB-1242 / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
11097-69-1 / PCB-1254 / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
11104-28-2 / PCB-1221 / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
11141-16-5 / PCB-1232 / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
12672-29-6 / PCB-1248 / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
11096-82-5 / PCB-1260 / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
12674-11-2 / PCB-1016 / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
8001-35-2 / Toxaphene / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
57-12-5 / Cyanide, Total / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
471-34-1 / Hardness (as CaCO3) / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
Total Phenolic Compounds / _____ / ( ) / _____ / ( ) / _____ / ( ) / _____ / ( )
Data Substitution Codes

AA Below Detectable Limit

PROGRAM EVALUATION

1)Approved Program Components:

a) Review of changes to State and/or Federal pretreatment regulations during the past year.

b) Review of the adequacy of the sewer use ordinance.

c) Review of operating procedures of the pretreatment program.

d) Discussion of method of funding the pretreatment program and annual budget.

e) Review of adequacy of local limits.

2) Accomplishments:

3) Problems:

4)Program Modifications:

Form 4117, 4221 (9/16)AR-1