**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 ent e r 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 : T he most recent date on which the Control Authority has adopted new local limits within the reporting period : Local Limits Evaluation Date : T he most recent date on which the Control Authority evaluated the need for local limits within the reporting period. Local Limits Pollutants : T he list of the pollutants for which the Control Authority derived local limits . TheControl Authority will only need to enter each pollutant once no matter how many treat ment 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 wi thin 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 Industria l 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 Sig nificant Industrial User (SIU) and Non -Significant Categorical Industrial User (NSCIU) that is discharging (including truck transportation) to this POTW the total wastewater fl ow rate (in gallons per day) in the previous reporting period. Middle -Tier Sign ificant 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). Th is 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 Ev** **ents by**  **Control Authority Number of Required**  **Industrial User Self** **** **Monitoring Events Actual Number of**  **Industrial User Self****** **Monitoring 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 elemen t 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 Indu strial 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 Industria l 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 pretre atment 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 pretre atment 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 wheth er 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 Non Significant 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 Requirement s : 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 S ignificant Non - Compliance (SNC) w ith 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 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 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 Industri al 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 Author ity to develop and enforce local limits when the discharge from an IU causes o r 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 Co ntrol 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 eac h 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 asse ssed 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 Enforceme nt 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 Industria l 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