Pretreatment Program Annual Report 

Required by EPA Regulation - 403.12(i)

Example Data Entry Form

[Note: Users will also be able to batch this data into this form via a spreadsheet or CSV file.]

NPDES Number <system generated>

Start Date of Reporting Period (YYYY-MM-DD)

End Date of Reporting Period (YYYY-MM-DD) 

NPDES Data Group Number 7

<system generated>

Summary of Control Authority Program Information in Reporting Period

Please use the following fields to enter data related to the overall approved pretreatment program for the reporting period.

Control Authority Resources: A unique code/description that identifies whether the pretreatment program 

has sufficient resources (e.g., budget, full-time equivalent labor) to fully implement its pretreatment 

program.

Local Limits Adoption Date: The most recent date on which the Control Authority has adopted new local 

limits within the reporting period:

Local Limits Evaluation Date: The most recent date on which the Control Authority evaluated the need for 

local limits within the reporting period.

Local Limits Pollutants: The list of the pollutants for which the Control Authority derived local limits. The 
Control Authority will only need to enter each pollutant once no matter how many treatment works are 

managed by the Control Authority.

POTW Discharge Contamination Indicator: A unique code/description that identifies whether there have 

been any problems (e.g., pass-through or interference) with the receiving POTW’s effluent discharge within 

the reporting period.

POTW Biosolids Contamination Indicator: A unique code/description that identifies whether there have 

been any problems (e.g., pass-through or interference) with the receiving POTW’s biosolids within the 

reporting period.
Summary of SIU/CIU/NSCIU/MTCIU/DIU Facility & Control Mechanism Information in Reporting Period

Please use the following table to provide data related to each SIU/CIU/NSCIU/MTCIU in your approved pretreatment program.

FRS ID

Industrial 

User Type 

Flag 

Industrial User 

Control 

Mechanism Flag

Industrial User 

Control Mechanism 

Effective Date 

Industrial User 

Control Mechanism 

Expiration Date 

Industrial User 

Wastewater Flow 

Rate

Middle-Tier Significant 

Industrial User Reduced 

Reporting Flag

* *

* *

* *

* *

*Note: These data will be pre-populated with data from ICIS-NPDES or the Approval Authority’s database. POTWs can add new 

SIU/CIU/NSCIU/MTCIU’s to this table as well as provide recommendations for updates to existing SIU/CIU/NSCIU/MTCIU data.

Industrial User Control Mechanism Flag: A unique code/description that identifies whether the Industrial User has a Control 

Mechanism.

Industrial User Control Mechanism Effective Date: The date when the Control Mechanism for the Industrial User is effective.

Industrial User Control Mechanism Expiration Date: The date when the Control Mechanism for the Industrial User will expire.

Industrial User Wastewater Flow Rate: This data element will identify for each Significant Industrial User (SIU) and Non-Significant 

Categorical Industrial User (NSCIU) that is discharging (including truck transportation) to this POTW the total wastewater flow rate 

(in gallons per day) in the previous reporting period.

Middle-Tier Significant Industrial User Reduced Reporting Flag: This code/description will identify for each Middle-Tier Significant 

Industrial User (MTSIU) whether the Control Authority has granted reduced reporting requirements in accordance with 40 CFR 

403.12(e)(3). This field can be left blank for Industrial Users that are not MTSIU.
Summary of POTW Inspection and IU Compliance Monitoring Data in Reporting Period

FRS ID

Number of 

Industrial User 

Inspections by 

Control Authority

Number of 

Industrial User 

Sampling Events by 

Control Authority

Number of Required 

Industrial User SelfMonitoring Events 

Actual Number of 

Industrial User SelfMonitoring Events

Non-Significant Categorical 

Industrial User (NSCIU) 

Certification Submitted to 

Control Authority

*

*

*

*Note: These data will be pre-populated with data from ICIS-NPDES or the Approval Authority’s database and the above 

SIU/CIU/NSCIU/MTCIU/DIU Facility Information table.

Number of Industrial User Inspections by Control Authority: This data element will identify for each Significant Industrial User (SIU), 

Dental Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) the number of inspections conducted by the 

Control Authority in the reporting period.

Number of Industrial User Sampling Events by Control Authority: This data element will identify for each Significant Industrial User 

(SIU), Dental Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) the number of complete sampling events 

conducted by the Control Authority in the reporting period.

Number of Required Industrial User Self-Monitoring Events: This data element will identify for each Significant Industrial User (SIU), 

Dental Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) the number of required self-monitoring 

sampling events in the reporting period that must be reported to the Control Authority.

Actual Number of Industrial User Self-Monitoring Events: This data element will identify for each Significant Industrial User (SIU), 

Dental Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) the actual number of self-monitoring sampling 

events in the reporting period submitted to the Control Authority.

Non-Significant Categorical Industrial User (NSCIU) Certification Submitted to Control Authority: This code/description will identify 

for each Non-Significant Categorical Industrial User (NSCIU) and Dental Industrial User (DIU) whether it has given its required annual 

compliance certification within the reporting period.
Summary of SIU/CIU/NSCIU/MTCIU/DIU Violation Determinations in Reporting Period

Please use the following table to provide data related to your violation determinations for each SIU/CIU/NSCIU/MTCIU/DIU in your 

approved pretreatment program.

FRS 

ID

SNC with Pretreatment 

Enforceable Compliance 

Schedule Flag

SNC with 

Pretreatment 

Standards

SNC with 

Pretreatment 

Standards 

Pollutants

SNC with 

Reporting 

Requirements

SNC with 

Other Control 

Mechanism 

Requirements

Listing of 

Months in

SNC

Industrial User 

POTW 

Contamination 

Indicator

Industrial User 

Biosolids 

Contamination 

Indicator

*

*

*

*

*Note: These data will be pre-populated with data from the above SIU/CIU/NSCIU/MTCIU/DIU Facility Information table.

SNC with Pretreatment Enforceable Compliance Schedule Flag: A unique code/description that identifies whether each Industrial 

Users (SIU) and Non-Significant Categorical Industrial Users (NSCIU) in SNC has one or more enforceable compliance pretreatment 

schedule(s).

SNC with Pretreatment Standards: This data element will identify for each Significant Industrial User (SIU) and Non-Significant 

Categorical Industrial User (NSCIU) that is discharging (including truck transportation) to this POTW whether the IU was in Significant 

Non-Compliance (SNC) with pretreatment requirements in the reporting period.

SNC with Pretreatment Standards Pollutants: This data element will identify for each Significant Industrial User (SIU) and NonSignificant Categorical Industrial User (NSCIU) that is discharging (including truck transportation) the pollutants that related to the 

IU’s Significant Non-Compliance (SNC) status with pretreatment requirements in the reporting period.

SNC with Reporting Requirements: This data element will identify for each Significant Industrial User (SIU) and Non-Significant 

Categorical Industrial User (NSCIU) that is discharging (including truck transportation) to this POTW whether the IU was in Significant 

Non-Compliance (SNC) with reporting requirements (including baseline monitoring reports, notice of potential problems, periodic 

self-monitoring reports, notice of change in Industrial User discharge, hazardous waste notification and BMP certification) in the

reporting period.
SNC with Other Control Mechanism Requirements: This data element will identify for each Significant Industrial User (SIU) and NonSignificant Categorical Industrial User (NSCIU) that is discharging (including truck transportation) to this POTW whether the IU was in 

Significant Non-Compliance (SNC) with any other control mechanism requirements in the reporting period.

Listing of Months in SNC: This data element will identify for each Significant Industrial User (SIU) and Non-Significant Categorical 

Industrial User (NSCIU) that is discharging (including truck transportation) to this POTW the month or months the IU is in SNC in the

reporting period. These data must be provided in YYYY-MM format where YYYY is the year and MM is the month.

Industrial User POTW Discharge Contamination Indicator: This data element will identify for each Significant Industrial User (SIU), 

Dental Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) whether the Industrial User caused or 

contributed to any problems with the receiving POTW’s effluent discharge in the previous reporting period. EPA regulations require 

the Control Authority to develop and enforce local limits when the discharge from an IU causes or contributes to any problems (e.g., 

pass-through or interference) at the receiving POTW.

Industrial User Biosolids Contamination Indicator: This data element will identify for each Significant Industrial User (SIU), Dental 

Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) whether the Industrial User caused or contributed to 

any problems with the receiving POTW’s biosolids in the previous reporting period. EPA regulations require the Control Authority to 

develop and enforce local limits when the discharge from an IU causes or contributes to any problems (e.g., pass-through or 

interference) at the receiving POTW.
Summary of POTW Enforcement Actions in Reporting Period

Please use the following table to provide data related to your enforcement actions for each SIU/CIU/NSCIU/MTCIU/DIU in your 

approved pretreatment program.

FRS ID Types of Industrial User 

Enforcement Actions

Number of Industrial User Enforcement 

Actions 

Industrial User Cash Civil 

Penalty Amount Assessed

Cash Civil Penalty 

Amount Collected

SNC 

Published

*

*

*

*Note: These data will be pre-populated with data from the above SIU/CIU/NSCIU/MTCIU/DIU Facility Information table.

Types of Industrial User Enforcement Action: This data element will identify for each Significant Industrial User (SIU), Dental 

Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) the type(s) of enforcement action(s) (e.g., formal 

notices of violation or equivalent actions, administrative orders, civil suits, criminal suits) issued by the Control Authority in the 

reporting period.

Number of Industrial User Enforcement Actions: This data element will identify for each Significant Industrial User (SIU), Dental 

Industrial User, and Non-Significant Categorical Industrial User (NSCIU) and for each type of enforcement action the total number of 

enforcement actions issued by the Control Authority in the reporting period.

Industrial User Cash Civil Penalty Amount Assessed: For civil judicial Enforcement Actions, the dollar amount of the penalty assessed 

against each Significant Industrial User (SIU), Dental Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) in 

the reporting period as specified in the final entered Consent Decree or Court Order. For Administrative Enforcement Actions, it is 

the dollar amount of the penalty assessed in the Consent/Final Order.

Industrial User Cash Civil Penalty Amount Collected: For civil judicial Enforcement Actions, the dollar amount of the penalty collected 

from each Significant Industrial User (SIU), Dental Industrial User (DIU), and Non-Significant Categorical Industrial User (NSCIU) in the 

reporting period. For Administrative Enforcement Actions, it is the dollar amount collected of the penalty assessed in the 

Consent/Final Order.
Standard Signature Block and Certification 

Statement for CWA Reporting (in compliance 

with CFR Parts 3, 122.22, and 127).

SNC Published: A unique code/description that identifies whether public notice was made for each Significant Industrial Users (SIUs) 

and Non-Significant Categorical Industrial Users (NSCIUs) in SNC.

SUBMIT 

REPORT