Section IV – Wastewater Characteristics: Answer questions 1 or 2 below, as applicable. 1. Municipal facilities: Not Applicable a. Collection system: Separate (sanitary sewer only) Combined (sanitary sewer & storm water) Both separate and combined b. Does your facility accept septage? No Yes – Provide average monthly daily volume (gal/day): c. Is the facility receiving process wastewater from industrial customers? No – Skip questions 1.d & 1.e below and go to Section V Yes – Provide information for the industrial customers: i. Name: SIC code(s): SIC Description: Flow: Average: gal/day, Peak: gal/day ii. Name: SIC code(s): SIC Description: Flow: Average: gal/day, Peak: gal/day iii. Name: SIC code(s): SIC Description: Flow: Average: gal/day, Peak: gal/day
Section IV – Wastewater Characteristics: (Continued) d. Do(es) the industrial customer(s) listed above have a pre-treatment permit issued by the State? No Yes – Provide pre-treatment permit number(s): i. ii. iii. e. If the industrial facility(ies) listed above do(es) not have a pre-treatment permit, do you have an approved industrial pre-treatment program? No Yes – Provide approval date:
c. Original DDR concurrence date: d. DDR Amendment concurrence date(s): Section V – Description of the Treatment Facility: (Continued) All questions must be answered unless otherwise instructed. 3. Storage capacity: Not Applicable Provide volume for each storage pond or storage tank: a. gal d. gal b. gal e. gal c. gal f. gal 4. Is the treated wastewater land applied on a dedicated site? No – Go to Section VI. Yes – Answer questions below. 5. Irrigation system: Not Applicable a Provide a map or drawing showing: (If applying for a phased permit, provide information for all phases) Locations of all land application sites. Include ID and surface area for each irrigation zone or field. Locations of all groundwater monitoring wells. Groundwater monitoring wells should be identified by the following symbols: Upgradient wells U1, U2, U3, etc.; Midfield wells M1, M2, M3, etc.; Downgradient wells D1, D2, D3, etc. Surface water monitoring location(s). b. Type of system: (Check all that apply) i. Sprayfield Sprinklers Center pivot(s) ii. Dripfields Above-ground emitters Subsurface emitters iii. Drainfields Infiltration chambers Perforated pipes with gravel bed
Petroleum Refining x x x x Pharmaceutical Manufacturing x x x - Photographic Equipment and Supplies x x x x Plastics and Synthetic Materials Manufacturing x x x x Plastic Processing x - - - Pulp, Paper, and Paperboard x x x - Rubber Manufacturing x x x - Porcelain Enameling x - x x Printing and Publishing x x x x Soap and Detergent Manufacturing x x x - Steam Electric Power Generating x x x - Textile Mills x x x x Timber Products Processing x x x x Section VII - Operational Data (Continued) b. All industrial applicants must provide analytical wastewater effluent data in the following table. Data must be representative of the effluent waste stream and analyzed using a sufficiently sensitive test method in accordance with 40 CFR Part 136. The table below is not an all-encompassing list. It is the responsibility of the applicant to ensure the effluent discharge has been adequately characterized and the applicable information is reported to EPD. i. All Applicants. If you believe a pollutant listed below may be present in your effluent discharge, place an “X” in the Believed Present box and provide the corresponding analytical data. ii. For Categorical Industrial Users Only. Check the box “Believed Present” and analyze the discharge for the corresponding type of pollutants for your specific industrial category. Refer to Section IV.2.a for specific industrial category. Pollutant Place “X” if Believed Present Average Sample Result (mg/L) Maximum Sample Result (mg/L) Number of Analyses EPA Test Method Toxic Metals, Cyanides, & Phenols Antimony, Total Arsenic, Total Beryllium, Total Copper, Total Cadmium, Total Chromium, Total Cyanide, Total Cyanide, Amenable Chromium, Hexavalent