Spreadsheet: 13bcc514-85ff-4e08-add7-4bc8a746cce4
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6
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:
Authorized Signatory:
Name on Water Bill:
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: |  |  | 0
No. of work days in report period: |  |  |  | [NAME]. daily water use:
No. of employees:
Production Volume in report period: |  |  |  |  | [NAME]. daily production: ___________
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. | a.  Hours of Industrial 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)
2. | 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 per batch: |  |  |  |  | (gal/batch)
 | d.  Average flow rate per batch: |  |  |  |  | (gal/minute)
3. | [NAME] any process changes or expansions planned during 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 occurred to these documents in the past six (6) months,
please submit these changes.
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 standard 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 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 an SCP 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
 | maintaining 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 the 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
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)