GreensvilleCounty Water & Sewer Authority
1781 Greensville County Circle
Emporia, VA 23847
Phone (434) 348-4205
APPLICATION FOR INDUSTRIAL USER DISCHARGE PERMIT
Section A – General Information
A.1.Company name, mailing address and telephone number:
______
A.2.Location address of production or manufacturing facility:
______
A.3.Name, title and telephone number of person authorized to represent this firm in official dealings with the Authority:
______
A.4.Alternate person to contact concerning the information provided herein:
______
A.5.Identify the type of business conducted (auto repair, machine shop, electroplating, warehouse, painting, printing, meat packing, food processing, etc.)
______
______
______
A.6.Provide a brief narrative description of the manufacturing, production or service activities your firm conducts:
______
______
______
______
______
______
______
______
______
A.7Standard Industrial Classification Number(s) (SIC Code) for your facility:
______
A.8.This facility generates the following types of wastes (Check all that apply):
AverageGallons per Day
1. / ( ) Domestic wastes (restrooms, showers, etc. / ______/ ( ) estimated / ( ) measured
2. / ( ) Cooling water, non-contact / ______/ ( ) estimated / ( ) measured
3. / ( ) Boiler/Tower blowdown / ______/ ( ) estimated / ( ) measured
4. / ( ) Cooling water, contact / ______/ ( ) estimated / ( ) measured
5. / ( ) Process / ______/ ( ) estimated / ( ) measured
6. / ( ) Equipment/Facility Washdown / ______/ ( ) estimated / ( ) measured
7. / ( ) Air Pollution Control Unit / ______/ ( ) estimated / ( ) measured
8. / ( ) Storm water runoff to sewer / ______/ ( ) estimated / ( ) measured
9. / ( ) Other / ______/ ( ) estimated / ( ) measured
Total A.8.1 – A.8.9 / ______
A.9.Wastes are discharged to (check all that apply):
AverageGallons per Day
( ) Sanitary sewer / ______/ ( ) estimated / ( ) measured
( ) Storm water / ______/ ( ) estimated / ( ) measured
( ) Surface water / ______/ ( ) estimated / ( ) measured
( ) Ground water / ______/ ( ) estimated / ( ) measured
( ) Waste haulers / ______/ ( ) estimated / ( ) measured
( ) Evaporation / ______/ ( ) estimated / ( ) measured
( ) Other / ______/ ( ) estimated / ( ) measured
Provide name and address of waste hauler(s), if used.
______
______
A.10.Is a Spill Prevention Control and Countermeasure Plan prepared for the facility?
( )YES( )NO
Section B – Facility Operation Characteristics
B.1.Total number of employees ______Number of shifts ______
B.2.Employees on Shift 1 ______Hrs of Shift ______Workdays ______
Employees on Shift 2 ______Hrs of Shift ______Workdays ______
Employees on Shift 3 ______Hrs of Shift ______Workdays ______
*****NOTE: The following information in this section must be complete for each product line.
B.3.Principal product produced:
B.4.Raw materials and process additives used:
______
______
B.5.Production process is:
( ) Batch______% Batch
( ) Continuous ______% Continuous
( ) Both
B.6.Hours of operation:______a.m.to ______p.m.( ) continuous
B.7.Is production subject to seasonal variation?( )YES( )NO
B.8.Are any process changes or expansion planned during the next three years?
( )YES( )NO
If yes, explain below:
Additional product line information should be explained on a separate sheet.
Section C – Wastewater Information
C.1.If your facility employs processes in any of the industrial categories or business activities listed below and any of these processes gene rate wastewater or waste sludge, place a check beside the category or business activity (check all that apply).
- Industrial Categories
( ) Adhesives and Sealants / ( ) Nonferrous Metals Manufacturing
( ) Aluminum Forming / ( ) Ore Mining and Dressing
( ) Auto and other Laundries / ( ) Organic Chemicals
( ) Battery Manufacturing / ( ) Paint and Ink Formulating
( ) Circuit board Manufacturing / ( ) Pesticides Chemicals
( ) Coal Mining / ( ) Petroleum Refining
( ) Coil Coating / ( ) Pharmaceutical Manufacturing
( ) Copper Forming / ( ) Photographic Equipment and Supplies
( ) Electric & Electronic Components / ( ) Plastics & Synthetic Materials
( ) Electroplating and Electroless Plating / ( ) Plastics Processing
( ) Explosives Manufacturing / ( ) Porcelain Enameling
( ) Foundaries / ( ) Printing and Publishing
( ) Gum and Wood Chemicals / ( ) Pulp, Paper, and Paperboard
( ) Inorganic Chemicals / ( ) Rubber
( ) Iron and Steel Manufacturing / ( ) Soaps & Detergents
( ) Leather Tanning and Finishing / ( ) Steam Electric Power Generating
( ) Mechanical Products / ( ) Textile Mills
( ) Metal Finishing / ( ) Timber Products
- Other Business Activity
( ) Dairy Products
( ) Slaughter/Meat Packing/Rendering
( ) Food/Edible Products Processor
( ) Beverage Bottler
C2.Pretreatment devices or processed used for treating wastewater or sludge
(check as many appropriate)
( ) Air flotation / ( ) Reverse Osmosis( ) Centrifuge / ( ) Screen
( ) Chemical precipitation / ( ) Sedimentation
( ) Chlorination / ( ) Septic Tank
( ) Cyclone / ( ) Solvent separation
( ) Filtration / ( ) Spill protection
( ) Flow Equalization / ( ) Sump
( ) Grease or oil separation, type ______/ ( ) Biological treatment, type ______
( ) Grease trap / ( ) Rainwater diversion or storage
( ) Grit removal / ( ) Other chemical treatment, type ____
( ) Ion Exchange / ( ) Other physical treatment, type _____
( ) Neutralization, pH correction / ( ) Other, type ______
( ) Ozonation / ( ) No pretreatment provided
C.3.If any wastewater analyses have been performed on the wastewater discharge(s) from your facilities, attach a copy of the most recent data to this questionnaire. Be sure to include the date of the analysis, name of the laboratory performing the analysis, and the location(s) from which the sample(s) were taken (attach sketches, plans, etc., as necessary).
C.4.Priority Pollutant Information: Please indicate by placing an “x” in the appropriate box by each listed chemical whether it is “Suspected to be Absent”, “Known to be Absent”, “Suspected to be Present”, or “Known to be Present” in your manufacturing or service activity or generated as a by-product.
CHEMICAL COMPOUND / Known Present / Suspected Present / Known Absent / SuspectedAbsent / Known or Suspected Concentration/day
I. / METALS & INORGANICS / ( ) / ( ) / ( ) / ( ) / ______
1. / Antrimony / ( ) / ( ) / ( ) / ( ) / ______
2. / Arsenic / ( ) / ( ) / ( ) / ( ) / ______
3. / Asbestos / ( ) / ( ) / ( ) / ( ) / ______
4. / Beryllium / ( ) / ( ) / ( ) / ( ) / ______
5. / Cadmium / ( ) / ( ) / ( ) / ( ) / ______
6. / Chromium / ( ) / ( ) / ( ) / ( ) / ______
7. / Copper / ( ) / ( ) / ( ) / ( ) / ______
8. / Cyanide / ( ) / ( ) / ( ) / ( ) / ______
9. / Lead / ( ) / ( ) / ( ) / ( ) / ______
10. / Mercury / ( ) / ( ) / ( ) / ( ) / ______
11. / Nickel / ( ) / ( ) / ( ) / ( ) / ______
12. / Selenium / ( ) / ( ) / ( ) / ( ) / ______
13. / Silver / ( ) / ( ) / ( ) / ( ) / ______
14. / Thallium / ( ) / ( ) / ( ) / ( ) / ______
15. / Zinc / ( ) / ( ) / ( ) / ( ) / ______
II / PHENOLS & CRESOLS
16. / Phenol(s) / ( ) / ( ) / ( ) / ( ) / ______
17. / Phenol, 2-chloro / ( ) / ( ) / ( ) / ( ) / ______
18. / Phenol, 2, 4-dichloro / ( ) / ( ) / ( ) / ( ) / ______
19. / Phenol, 2, 4, 6-tri-chloro / ( ) / ( ) / ( ) / ( ) / ______
20. / Phenol, pentachloro / ( ) / ( ) / ( ) / ( ) / ______
21. / Phenol, 2-nitro / ( ) / ( ) / ( ) / ( ) / ______
22. / Phenol, 4-nitro / ( ) / ( ) / ( ) / ( ) / ______
23. / Phenol, 2, 4 -dinitro / ( ) / ( ) / ( ) / ( ) / ______
24. / Phenol, 2, 4-dimethyl / ( ) / ( ) / ( ) / ( ) / ______
25. / m-Cresol, p-chloro / ( ) / ( ) / ( ) / ( ) / ______
26. / o-Cresol, 4, 6-dinitro / ( ) / ( ) / ( ) / ( ) / ______
CHEMICAL COMPOUND / Known Present / Suspected Present / Known Absent / Suspected
Absent / Known or Suspected Concentration/day
III. / MONOCYCLIC AROMATICS (EXCLUDING PHENOLS, CRESOLS
AND PHTHALATES)
27. / Benzene / ( ) / ( ) / ( ) / ( ) / ______
28. / Benzene, chloro / ( ) / ( ) / ( ) / ( ) / ______
29. / Benzene, 1, 2-dichloro / ( ) / ( ) / ( ) / ( ) / ______
30. / Benzene, 1, 3-dichloro / ( ) / ( ) / ( ) / ( ) / ______
31. / Benzene, 1, 4-dichloro / ( ) / ( ) / ( ) / ( ) / ______
32. / Benzene, 1, 2, 4-trichloro / ( ) / ( ) / ( ) / ( ) / ______
33. / Benzene, hexachloro / ( ) / ( ) / ( ) / ( ) / ______
34. / Benzene, ethyl / ( ) / ( ) / ( ) / ( ) / ______
35. / Benzene, nitro / ( ) / ( ) / ( ) / ( ) / ______
36. / Toluene / ( ) / ( ) / ( ) / ( ) / ______
37. / Toluene, 2, 4-dinitro / ( ) / ( ) / ( ) / ( ) / ______
38. / Toluene, 2, 6-dinitro / ( ) / ( ) / ( ) / ( ) / ______
IV. / PCBs & RELATED COMPOUNDS
39. / PBC-1016 / ( ) / ( ) / ( ) / ( ) / ______
40. / PBC-1221 / ( ) / ( ) / ( ) / ( ) / ______
41. / PBC-1232 / ( ) / ( ) / ( ) / ( ) / ______
42. / PBC-1242 / ( ) / ( ) / ( ) / ( ) / ______
43. / PBC-1248 / ( ) / ( ) / ( ) / ( ) / ______
44. / PBC-1254 / ( ) / ( ) / ( ) / ( ) / ______
45. / PBC-1260 / ( ) / ( ) / ( ) / ( ) / ______
46. / 2-Chloronaphthalene / ( ) / ( ) / ( ) / ( ) / ______
V. / ETHERS
47. / Ether, bis (chloromethyl) / ( ) / ( ) / ( ) / ( ) / ______
48. / Ether, bis (2-chloroethyl) / ( ) / ( ) / ( ) / ( ) / ______
49. / Ether, bis (2-chlorosopropyl) / ( ) / ( ) / ( ) / ( ) / ______
50. / Ether, 2-chloroethyl vinyl / ( ) / ( ) / ( ) / ( ) / ______
51. / Ether,4-bromophenyl phenyl / ( ) / ( ) / ( ) / ( ) / ______
52. / Ether,4-chlorophenyl phenyl / ( ) / ( ) / ( ) / ( ) / ______
53. / Bis(2-chloroethoxy)methane / ( ) / ( ) / ( ) / ( ) / ______
VI. / NITROSAMINES & OTHER NITROGEN-CONTAINING COMPOUNDS
54. / Nitrosamine, dimethyl / ( ) / ( ) / ( ) / ( ) / ______
55. / Nitrosamine, diphenyl / ( ) / ( ) / ( ) / ( ) / ______
56. / Nitrosamine, di-n-propyl / ( ) / ( ) / ( ) / ( ) / ______
57. / Benzidine / ( ) / ( ) / ( ) / ( ) / ______
58. / Benzidine, 3, 3-dichloro / ( ) / ( ) / ( ) / ( ) / ______
59. / Hydrazine, 1, 2-diphenyl / ( ) / ( ) / ( ) / ( ) / ______
60. / Acrylonitrile / ( ) / ( ) / ( ) / ( ) / ______
CHEMICAL COMPOUND / Known Present / Suspected Present / Known Absent / Suspected
Absent / Known or Suspected Concentration/day
VII. / HALOGENATED ALIPHATICS
61. / Methane, bromo- / ( ) / ( ) / ( ) / ( ) / ______
62. / Methane, chloro- / ( ) / ( ) / ( ) / ( ) / ______
63. / Methane, dichloro / ( ) / ( ) / ( ) / ( ) / ______
64. / Methane, chlorodibromo / ( ) / ( ) / ( ) / ( ) / ______
65. / Methane, dichlorobromo / ( ) / ( ) / ( ) / ( ) / ______
67. / Methane, tribromo / ( ) / ( ) / ( ) / ( ) / ______
68. / Methane, trichloro / ( ) / ( ) / ( ) / ( ) / ______
69. / Methane, trichlorofluoro / ( ) / ( ) / ( ) / ( ) / ______
70. / Methane, dichlorodifluoro / ( ) / ( ) / ( ) / ( ) / ______
71. / Ethane, 1, 1-dichloro / ( ) / ( ) / ( ) / ( ) / ______
72. / Ethane, 1, 2-dichloro / ( ) / ( ) / ( ) / ( ) / ______
73. / Ethane, 1, 1, 1-trichloro / ( ) / ( ) / ( ) / ( ) / ______
74. / Ethane, 1, 1, 2-tetrachloro / ( ) / ( ) / ( ) / ( ) / ______
75. / Ethane, 1, 1, 2, 1-tetrachloro / ( ) / ( ) / ( ) / ( ) / ______
76. / Ethane, hexachloro / ( ) / ( ) / ( ) / ( ) / ______
77. / Ethene, chloro / ( ) / ( ) / ( ) / ( ) / ______
78. / Ethene, 1, 1-dichloro / ( ) / ( ) / ( ) / ( ) / ______
79. / Ethene, trans-dichloro / ( ) / ( ) / ( ) / ( ) / ______
80. / Ethene, trichloro / ( ) / ( ) / ( ) / ( ) / ______
81. / Ethene, tetrachloro / ( ) / ( ) / ( ) / ( ) / ______
82. / Propane, 1, 2-dichloro / ( ) / ( ) / ( ) / ( ) / ______
83. / Propane, 2, 4-dichloro / ( ) / ( ) / ( ) / ( ) / ______
84. / Butadiene, hexachloro / ( ) / ( ) / ( ) / ( ) / ______
85. / Cyclopentadiene,hexachloro / ( ) / ( ) / ( ) / ( ) / ______
VIII. / PHTHALATE ESTERS
86. / Phthalate, di-c-methyl / ( ) / ( ) / ( ) / ( ) / ______
87. / Phthalate, di-n-ethyl / ( ) / ( ) / ( ) / ( ) / ______
88. / Phthalate, di–n-butyl / ( ) / ( ) / ( ) / ( ) / ______
89. / Phthalate, di-n-octyl / ( ) / ( ) / ( ) / ( ) / ______
90. / Phthalate, bis(2-ethlhexyl) / ( ) / ( ) / ( ) / ( ) / ______
91. / Phthalate, butyl benzyl / ( ) / ( ) / ( ) / ( ) / ______
IX. / POLYCYCLIC AROMATIC HYDROCARBONS
92. / Acenaphthene / ( ) / ( ) / ( ) / ( ) / ______
93. / Acenaphthylene / ( ) / ( ) / ( ) / ( ) / ______
94. / Anthracene / ( ) / ( ) / ( ) / ( ) / ______
95. / Benzo (a) anthracene / ( ) / ( ) / ( ) / ( ) / ______
96. / Benzo (b) fluoranthene / ( ) / ( ) / ( ) / ( ) / ______
97. / Benzo (k) fluoranthene / ( ) / ( ) / ( ) / ( ) / ______
98. / Benzo (ghi) perylene / ( ) / ( ) / ( ) / ( ) / ______
99. / Benzo (a) pyrene / ( ) / ( ) / ( ) / ( ) / ______
CHEMICAL COMPOUND / Known Present / Suspected Present / Known Absent / Suspected
Absent / Known or Suspected Concentration/day
100. / Chrysene / ( ) / ( ) / ( ) / ( ) / ______
101. / Dibenzo (a, n) anthracene / ( ) / ( ) / ( ) / ( ) / ______
102. / Fluoranthene / ( ) / ( ) / ( ) / ( ) / ______
103. / Fluorene / ( ) / ( ) / ( ) / ( ) / ______
104. / Indeno (1, 2, 3-cd) pyrene / ( ) / ( ) / ( ) / ( ) / ______
105. / Naphthalene / ( ) / ( ) / ( ) / ( ) / ______
106. / Phenanthrene / ( ) / ( ) / ( ) / ( ) / ______
107. / Pyrene / ( ) / ( ) / ( ) / ( ) / ______
X. / PETICIDES
108. / Acrolein / ( ) / ( ) / ( ) / ( ) / ______
109. / Aldrin / ( ) / ( ) / ( ) / ( ) / ______
110. / BHC (Alpha) / ( ) / ( ) / ( ) / ( ) / ______
111. / BHC (Beta) / ( ) / ( ) / ( ) / ( ) / ______
112. / BHC (Gamma) or Lindane / ( ) / ( ) / ( ) / ( ) / ______
113. / BHC (Delta) / ( ) / ( ) / ( ) / ( ) / ______
114. / Chlordane / ( ) / ( ) / ( ) / ( ) / ______
115. / DDD / ( ) / ( ) / ( ) / ( ) / ______
116. / DDE / ( ) / ( ) / ( ) / ( ) / ______
117. / DDT / ( ) / ( ) / ( ) / ( ) / ______
118. / Dieldrin / ( ) / ( ) / ( ) / ( ) / ______
119. / Endosulfan (Alpha) / ( ) / ( ) / ( ) / ( ) / ______
120. / Endosulfan (Beta) / ( ) / ( ) / ( ) / ( ) / ______
121. / Endosulfan Sulfate / ( ) / ( ) / ( ) / ( ) / ______
122. / Endrin / ( ) / ( ) / ( ) / ( ) / ______
123. / Endrin aldehyde / ( ) / ( ) / ( ) / ( ) / ______
124. / Heptachlor / ( ) / ( ) / ( ) / ( ) / ______
125. / Heptachlor epoxide / ( ) / ( ) / ( ) / ( ) / ______
126. / Isophorone / ( ) / ( ) / ( ) / ( ) / ______
127. / TCDD (or Dioxin) / ( ) / ( ) / ( ) / ( ) / ______
128. / Toxaphene / ( ) / ( ) / ( ) / ( ) / ______
Section D – Other Wastes
D.1.Are any liquid wastes or sludges from this firm disposed of by means other than discharge to the sewer system? ( ) YES ( ) NO
If YES, complete items 2 and 3.
If NO, skip remainder of Section D.
D.2.These wastes may be described as:
Estimated Gallons or Pounds/Year
( )Acids and Alkalies______
( )Heavy Metal Sludges______
( )Inks/Dyes______
( )Oils and/or Grease______
( )Organic Compounds______
( )Paints______
( )Pesticides______
( )Plating Wastes______
( )Pretreatment Sludges______
( )Solvents/Thinners______
( )Other Hazardous Wastes (specify)______
______
______
( )Other Wastes (specify)______
______
______
D.3.For the above checked wastes, does your company practice:
( )on-site storage
( ) off-site storage
( )on-site disposal
( )Off-site disposal
Briefly describe the method(s) of storage or disposal checked above.
Section E – Signatory Page
Note to Signing Official:In accordance with Title 40 of the Code of Federal Regulations Part 403, Section 403.14, information and data provided in this questionnaire 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 40 CFR Part 2. Should a discharge permit be required for your facility, the information in this questionnaire will be used to issue the permit.
This is to be signed by an authorized official of your firm after adequate completion of this form and review of the information by the signing official.
I have personally examined and am familiar with the information submitted in this document and attachments. Based upon my inquiry of those individuals immediately responsible for obtaining the information reported herein, I believe that the submitted information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and/or imprisonment.
______
Signature of OfficialDate
APPENDIX H
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