Hazardous Waste Discharge Reporting Notification

3780 South 1550 West St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Hazardous Waste Discharge Reporting Notification
Directions for Completing the Hazardous Waste Discharge Reporting Notification Form

1. The St. George Regional Water Reclamation Facility requires certain information from all businesses that discharge wastewater to its wastewater treatment plant.

2. Please complete this Hazardous Waste Discharge Reporting Notification form. Answer all questions as completely as possible. If you do not know the answer to a question, write “Unknown” in the box. If an answer is not applicable to your facility, write “N/A”.

3. Please sign and return the Hazardous Waste Discharge Reporting Notification Form within 30 days. Form must be signed by an authorized representative of the business.

4. Failure to complete and submit the Hazardous Waste Discharge Reporting Notification form is a violation of the SGRWRF Pretreatment Ordinance.

5. If your facility falls under the Hazardous Waste Pharmaceutical Rule as outlined in FR 5816 (02/2019) then complete Section 3. If not, then complete Section 4.

6. If you have any questions, please contact the SGRWRF Pretreatment Department at: (435) 627-4273 or (435) 627-4284.
Facility Name (or dba) *
Physical Street Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Authorized Representative's Name *
Title
Phone Number *

Area Code Phone Number
Application Date

Month Day Year
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Contact Email Address *
example@example.com
Section 1

List all Standard Industrial Classification (SIC) or NAICS codes for the Company’s facility:
Section 2

State of Utah or EPA Hazardous Waste I.D. Number:
Utah DEQ
EPA
Section 3

Applicable to Hazardous Waste Pharmaceutical Rule as outlined in 84 FR 5816 (2/2019):
Type a question

Drug Wholesalers Supermarkets and other Grocery (except convenience) Stores Pharmacies and Drug Stores Warehouse Clubs and Supercenters Veterinary Services Physician Office Dentist Office Other Health Practitioners (e.g., Medical Labs, Chiropractors, Jail or Dentation Center, Clinics, Mental and Behavioral Health Services) Outpatient Care Center (e.g., Dialysis center, Cancer Treatment center, Diabetes clinic) Other Ambulatory Health Care Services ( Orthopedic services) Hospital Nursing Care Facility (e.g., Assisted Living Facility, Nursing Home, Rehabilitation Service, Addiction Treatment Center, Group Home, Women/Children Shelter) Continuing Care Retirement Community (e.g., Assisted Living Facilities with on-site nursing facilities) Reverse Distributors
Section 4

Check any and all activities occurring at the Company’s facility
Type a question

Aircraft repair/ maintenance Automotive/Garage/Car Wash/Detailing Brewery Copper or aluminum forming Dairy products manufacturing Electrical component manufacturing Fertilizer manufacture Firearms- bluing Glass manufacturing Iron work Laundry Leather tanning Leather tanning and finishing Meat, vegetable or food processing (factory level, not restaurants) Metal Recycling Metal finishing (including electroplating, electroless plating, anodizing, coloring, coating, acid rinse or acid cleaning prior to Painting, chemical etching, etc.) Metal molding and casting Non-ferrous metals forming Oil and gas refining/ extraction Paint/ink manufacturing Painting of metal and/or powder coating Photographic/ x-ray developing Plastics manufacturing Plastic and Synthetic materials manufacturing Porcelain enameling Printing/ publishing Restaurant or fast food establishment Retail sales only Smelting/ metal refining Soap or detergent manufacture Treating wastes from other businesses Transportation equipment cleaning Timber products Trucked and hauled waste, including domestic septic tanks, sand traps, and grease interceptors (commercial or industrial) Wood preserving Warehouse
Other (Describe):
HAZARDOUS WASTE DISCHARGE REPORTING NOTIFICATION

This notification is intended to inform your business of their obligations under Section R317-8-8-11(14) d. of the State of Utah Water Quality Regulations. These requirements are for the reporting of discharges of hazardous waste to the sanitary sewer system.

The User shall notify the SGRWRF, the EPA Regional Waste Management Division Director, and State hazardous waste authorities in writing of any discharge into the sanitary sewer system of a substance, which, if otherwise disposed of, would be a hazardous waste under 40 CFR Part 261.

Such notification must include the name of the hazardous waste as set forth in 40 CFR Part 261, the EPA hazardous waste number, and the type of discharge (continuous, batch, or other). The SGRWRF is requiring this notification for a discharge of hazardous waste to the sanitary sewer system and the report shall be made immediately upon learning of the discharge.
Signatory Requirement
“I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based upon 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 fine and/or imprisonment for knowing violations.”
Name

First Name Last Name
Title
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Hazardous Waste Discharge Reporting Notification

Section 1

Section 2

Section 3

Section 4

Signatory Requirement