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Sheet: Sheet1

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ENVIRONMENTAL SERVICES DEPARTMENT
PRETREATMENT SEMI-ANNUAL REPORT
Reporting Period:
INDUSTRY PERMIT NO. |  |  |  |  |  | SIC CODE:
PROCESS:
SECTION A - GENERAL INFORMATION
Industry Name:
Street Address:
Phone: |  |  |  |  | Fax:
Industry Representative: |  |  |  |  | E-mail Address:
Authorized Signatory:
Name on Water Bill:
Part 1.  Monthly water use figures per account, as shown on water bills for reporting period:
(Please include copies of water bills)
Account No. |  |  | Month |  |  | Consumption (in gals)
 |  |  | Total Consumption:
No. of work days in report period: |  |  |  | [NAME]. daily water use:
[NAME]. no. of employees in report period:
Production Volume in report period: |  |  |  |  | [NAME]. daily production: _______________
Part 2.  List water usage on premises - list by account(s) and base calculations on no. of work days
Account No. | Type |  |  |  |  | Average Water | Estimated (E)
 |  |  |  |  |  | Usage (gal/day) | Measured (M)
 | a.  Contact cooling water
 | b.  Non-contact cooling water
 | c.  [NAME] feed
 | d.  Process
 | e.  Sanitary
 | f.   Air pollution control
 | g.  Contained in product
 | h.  Plant/equipment washdown
 | i.  Irrigation and lawn watering
 | j.  Other _________________
 |  |  |  |  | TOTAL:
[NAME] DISCHARGES
Provide the following information on discharge flow rate for this six month reporting period:
1. | Average Wastewater Volume Discharged from Non-Manufacturing Operations (gpd)
2. | Average Wastewater Volume Discharged from Manufacturing Support Operations (gpd)
3. | Average Wastewater Volume Discharged from the Manufacturing Process (gpd)
 | a.  If a continuous discharge:  Hours of Manufacturing Process Discharge (e.g., 9 a.m. to 5 p.m. or
 | closed)
 | M |  |  | T
 | W |  |  | T
 | F |  |  | Sa
 |  |  |  | Su
 | [NAME] hourly flow rate (gal/hour):
 | [NAME] daily flow rate (gal/day)
 | d.  Daily average flow rate (gal/day)
 | If batch discharge occurs or will occur, indicate:
 | a.  If batch discharges occur, give the number of occurrences:
 | 1. | Daily
 | 2. | Weekly
 | 3. | Monthly
 | [NAME] of batch discharges (e.g. 9 a.m. to 10 a.m.)
 | 1.
 | 2.
 | 3.
 | c.  Average discharge volume per batch: |  |  |  |  | (gal/batch)
 | d.  Average flow rate per batch: |  |  |  |  | (gal/minute)
3. | [NAME] any process changes or expansions planned in the next six months that could alter wastewater
 | volumes or characteristics?  Consider production processes as well as air or water pollution treatment
 | processes that may affect the discharge.
 | [       ] | Yes |  | [      ] | No
 | [NAME] any process changes occurred during the previous six months that have altered wastewater
 | volumes or characteristics?
 | [      ] | Yes |  | [      ] | No
4. | Briefly describe these changes and their effects on the wastewater volume and characteristics.
 | (Attach additional sheets if needed.)
5. | Are any materials or water reclamation systems in use or planned?
 | [      ] | Yes |  | [      ] | No
For questions 6 & 7, if a TOTAL TOXIC ORGANIC MANAGEMENT PLAN (TOMP) and a SLUG
CONTROL PLAN (SCP) have already been submitted, please do not submit these again.  However,
if any changes have been made to these documents in the past six (6) months,  please submit.
6. | For Industrial Users subject to Total Toxic Organics (TTO) Requirements:
 | a.  If Categorical, does (or will) this facility use any of the toxic organics that are listed under the TTO
 | standards of the applicable categorical pretreatment standards published by EPA?
 | [      ] | Yes |  | [      ] | No
 | [NAME] a TOMP been developed?
 | [      ] | Yes | (Please attach a copy if not previously submitted)
 | [      ] | No
CERTIFICATION STATEMENT
"Based on my inquiry of the person or persons directly responsible for managing compliance with the permit
limitation (or pretreatment standard) for total toxic organics (TTO), I certify that, to the best of my knowledge and
belief, no dumping of concentrated toxic organics into the wastewaters has occurred since the filing of the last
discharge monitoring report.  I further certify that this facility is implementing the toxic organic management plan
submitted to the permitting (or control) authority."
Signature |  |  |  |  |  | Date
7. | Do you have a Slug Control Plan to prevent spills of chemicals or slug discharges from entering
 | the Control Authority's collection system?
 | [      ] | Yes | (Please attach a copy if not previously submitted)
 | [      ] | No
8. | Please describe any previous spill events and remedial measures taken to prevent their reoccurrence.
SECTION C - PERMITTEE COMPLIANCE MONITORING REPORT
1. | The permittee is required to included all analyses on the permittee's discharge conducted in accordance
 | with 40CFR Part 136.  This includes all analyses conducted by the permittee, whether or not analyses
 | are required by the permit.  Use the attached form (Attachment #1) for recording your data.  Attach the
 | original Lab Report and Chain of Custody statement if not already submitted, otherwise, attach a copy of
 | the Lab Report.  If you have not performed any self-monitoring which is reportable, please state as such:
 | [     ] | Reportable self-monitoring has been performed
 | [     ] | Reportable self-monitoring has not been performed
2. | The following certified statement is an affirmation of the permittee's commitment to maintain compliance
 | with pretreatment standards at all times.
CERTIFIED STATEMENT
1. | Are all applicable Federal, State or local pretreatment standards and requirements being met on a
 | consistent basis?
 | [      ] | Yes |  | [      ] | No
 | If no, what additional operation and maintenance are required to insure compliance:
SECTION D - AUTHORIZED SIGNATURES
Authorized Representative Statement
I certify under penalty of law that this document and all attachments were prepared under my direction or
supervision with a system designed to assure that qualified personnel properly gather and evaluate the information
submitted.   Based on my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering information, the information submitted is, to the best of my knowledge and belief, true,
accurate and complete.  I am aware that there are significant penalties for submitting false information, including the
possibility of fines and imprisonment for knowing violations.
 | Name |  |  |  |  | Title
 | Signature |  |  | Date |  | Phone
(The original lab report and  chain of custody must be submitted along with this report.  If previously
submitted to the city, a copy with a notation that the original was previously submitted will suffice.)
Attachment No. 1 |  |  | [NAME]
Name of Waste Stream: |  |  |  |  |  | Sample Date:
Sample Type:
POLLUTANT or |  |  | Maximum Allowed |  |  | OBSERVED
POLLUTANT PROPERTY |  |  | Concentration (mg/L) |  |  | CONCENTRATION (mg/L)
Name of Laboratory conducting analyses:
(Attach original of laboratory report and chain of custody)