Automotive Permit Application

NARRAGANSETT BAY COMMISSION

Pretreatment Office
WASTEWATER DISCHARGE PERMIT APPLICATION AUTOMOTIVE OPERATIONS

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All sections of this permit application must be completed and properly signed by an official of the firm requesting to be issued a discharge permit in order for the Narragansett Bay Commission (NBC) to properly process this document. Submission of pretreatment plans, process plans, Spill and Slug Control plans, water bills, etc., wit h this application, if indicated within as being necessary, will expedite the permit issuance process. Please note that the discharge of process wastewater prior to the issuance of a discharge permit is a violation of the NBC Rules and Regulations and can subject the violator to an administrative penalty of up to $25,000 per violation per day. Should you require assistance in completing this document, do not hesitate to cont act the pretreatment staff at 461 -8848

Section A:

General Information
Check All That Apply

Proposed DischargeExisting Discharge
Standard Industrial Classification Code(s) (SIC)
Company Name
NAICS Code
Facility Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Premise Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number
Please enter a valid phone number.
Does the company own or rent the facility?
If rented, please provide the name of the property owner below

First NameLast Name
If rented, please provide the address of the property owner

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Designate Company Organization

ProprietorshipCorporationPartnership

If the company organization is designated as a corporation, the following section must be completed
President's Name

First NameLast Name
President's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
President's Phone Number
Please enter a valid phone number.
Vice President's Name

First NameLast Name
Vice President's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vice President's Phone Number
Please enter a valid phone number.
Secretary's Name

First NameLast Name
Secretary's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secretary's Phone Number
Please enter a valid phone number.
Treasurer's Name

First NameLast Name
Treasurer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Treasurer's Phone Number
Please enter a valid phone number.

Name, Title and Home Address of company owner(s) if sole proprietorship or partnership
Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

Section B:

Product or Service Information: Plant Operations Affecting the Characteristics of Discharge

List all Environmental Permits in Effect for the Facility

Detail all other water using operations:
Section E:

Wastewater Discharges, Characteristics and Control Measures
Are there any methods of water conservation practices at this facility?

YesNo
If yes, please explain.
Is any form of pretreatment practiced at this facility?

YesNo
If yes, list name(s) of Pretreatment System Operator(s)
For all wastestreams which are being treated before discharge, please type in the appropriate boxes for types of pretreatment used at this facility and indicate the wastestream treated:
Oil SeparationWastestream Treated
Grease TrapWastestream Treated
SedimentationWastestream Treated
FiltrationWastestream Treated
Chemical AdditionWastestream Treated

Neutralization/pH AdjustmentWastestream Treated
BiologicalWastestream Treated
EqualizationWastestream Treated
RecoveryWastestream Treated
Gasoline TrapWastestream Treated
Ion ExchangeWastestream Treated
Other (Please Specify)Wastestream Treated
Provide any additional information regarding pretreatment of process wastewater
Does your facility comply with the Narragansett Bay Commission effluent discharge limitations based on recent wastewater analysis?

YesNoDo Not Know
Attach a copy of any wastewater analyses which you may have

Cancelof
If No or Do Not Know, indicate steps and time schedules that will be followed in order to achieve full compliance.

Section F:

Chemicals Used and Stored on Premises
List all chemicals and solvents presently used or stored at your facility, along with their annual usage.
ChemicalAnnual Usage
ChemicalAnnual Usage
ChemicalAnnual Usage
ChemicalAnnual Usage
ChemicalAnnual Usage
Are any chemicals or solvents discharged to the sewer system?

YesNo
If Yes, please specify. (Chemical, gallons per day, etc)
Section G:

Boiler Rooms
Does your facility have a boiler room?

YesNo
If Yes, list type of fuel(s) utilized in facility boiler room.
If Yes, list all discharges from the boiler room (i.e, blowdown, condensate, etc.)
Wastewater SourceGallons Per Day Discharged
Wastewater SourceGallons Per Day Discharged
Wastewater SourceGallons Per Day Discharged
Are any floor drains, discharge sumps or open sewer connections located in the boiler room?

YesNo

Indicate all process tanks utilized at the facility.

Acid SoakCaustic SoakBoil Out TankTest TankOther
Please indicate the volume and the approximate dump frequency of each tank.
Acid Soak

VolumeDump Frequency
Caustic Soak

VolumeDump Frequency
Boil Out Tank

VolumeDump Frequency
Test Tank

VolumeDump Frequency
Other

VolumeDump Frequency
Designation of Authorized Agent:

I, First Name Last Name , certify that I am the Type a label of Type a label and that First Name Last Name is authorized to make submittals to the Narragansett Bay Commission (NBC) on behalf of Type a label and that said submittals are duly signed for and in behalf of said corporation by authority of its governing body, and are within the scope of its corporate powers.
Signature

Clear

NARRAGANSETT BAY COMMISSION