ZERO DISCHARGE

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., with 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 contact the pretreatment staff at 461-8848.

Zero Discharge Permit Application

WASTEWATER DISCHARGE PERMIT APPLICATION

SECTION A: GENERAL INFORMATION – Check all the apply:

Proposed DischargeExisting DischargeRecycle Process operation(s) With No DischargesRecycle Process operation(s) With Discharges

Standard Industrial Classification Code(s) (SIC)

NAICS Code

Company Name

Facility Mailing Address

Facility Premise Address

Business Phone Number

Does the company own or rent the facility?

If rented, provide the name and

the address of the property owner below:

Property Owner’s Name

Property Owner’s Address

Designate Company Organization:

Sole ProprietorshipCorporationPartnership

A Corporation under the laws of Type a label composed of officers as follows;

President's Name

Presidents Home Address

President's Home Phone

Vice President's Name

Vice President's Home Address

Vice President's Home Phone

Secretary

Secretary's Home Address

Secretary's Home Phone

Please enter a valid phone number.

Treasurer's Name

Treasurer's Home Address

Treasurer's Home Phone

Please enter a valid phone number.

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

1. Name

1. Title

1. Home Address

1. Home Telephone

2. Name

2. Title

2. Home Address

2. Home Telephone

3. Name

3. Title

3. Home Address

3. Home Telephone

List names of all agents authorized to make submittals to the NBC (attach additional sheet, if necessary):

1. Name

1. Title

1. Home Address

1. Home Phone

2. Name

2. Title

2. Home Address

2. Home Phone

NOTE: The NBC will accept the above-named person(s) as the company’s authorized agent(s) until notified otherwise.

Zero Discharge Permit Application

SECTION A: GENERAL INFORMATION (CONTINUED):

An authorized agent or authorized company representative is: (1) a person who is a principal executive officer or other corporate officer with signatory powers as per the company’s by-laws or (2) a person elected by a vote of the directors if the company is a corporation; (3) a general partner or proprietor if the company is a partnership or sole proprietorship respectively; (4) a duly authorized representative with responsibility for the overall operation of the facility and has the authority to sign contracts, permits, permit applications, monitoring results and other documents in the company’s name and otherwise bind the company. Please complete the Designation of Authorized agent

Section of this application to designate an authorized representative to make

submittals to the NBC on behalf of your firm. The NBC will not accept documents signed by persons other than the Company’s authorized agent(s) or authorized representative(s)

I have personally examined and am familiar with the information submitted in this document and attachments. Based upon my inquiry of those individuals immediately responsible for obtaining the information reported herein, I believe that the information submitted is true, accurate, and complete. I am aware that there are significant penalties for submitting false information including the possibility of fine and/or imprisonment.

Date

Signature of Company Official

DATESIGNATURE OF COMPANY OFFICIAL

Any information submitted to the Narragansett Bay Commission (NBC) pursuant to the pretreatment regulations and requirements authorized by R.I.G.L. 46-25-25

et seq. may be claimed as confidential by the submitter. This claim must be

asserted at the time of the submission in the manner described below. If no claim

is made at the time of the submission, the NBC or authorized state or federal

agencies may make the information available to the public without further notice.

Effluent data, however, shall at all times be available to the public without restriction.

A business confidentiality claim may be asserted by attaching or placing on this information, a cover sheet, or a stamped or typed legend upon each page, or other suitable form of notice employing language such as “trade secret”, “proprietary”, or “company confidential”. Allegedly confidential portions of otherwise non-confidential documents should be clearly identified as such, and may be submitted separately to facilitate identification and handling by the NBC. If confidential treatment is desired only until a certain date or until the occurrence of a certain event, this should also be clearly indicated. Information covered by such claims will be disclosed only to the extent, and by means of the procedures, set forth in the Federal EPA regulations at 40 CFR 2.

Zero Discharge Permit Application

SECTION A: GENERAL INFORMATION (CONTINUED):

10. List all Environmental Permits in Effect for the Facility:

	Permit Number	Permit Issued By	Purpose of Permit
1
2
3
4

SECTION B: PRODUCT OR SERVICE INFORMATION:

POPERATIONS AFFECTING THE CHARACTERISTICS OF DISCHARGE

Brief description of manufacturing or service activities performed on premises

Raw Materials Used

Principal Product or Service

Describe All Water Using Processes

Will there by any discharges to the sewer system?

YesNo

If yes, please specify

Zero Discharge Permit Application

SECTION C: PLANT OPERATIONAL CHARACTERISTICS (CONTINUED):

Type of Discharge

BatchContinuous

If batch, average number of batches per 24 hours

Is there a regularly scheduled shutdown period, such as for vacation?

YesNo

If yes, indicate weeks of normal shutdown. When?

Is production seasonal?

YesNo

If yes, explain indicating months (s) of peak production:

Shift information

	1st	2nd	3rd
Average Number of Employees per shift
Shift Start Times

If there are any special shifts, please list them here:

Indicate with check mark for each shift normally worked each day:

	Sun	Mon	Tue	Wed	Thu	Fri	Sat
1st
2nd
3rd

Is there a Spill and Slug Prevention Control and Countermeasures Plan in effect for this

YesNo

If yes, attach a copy of the facility Spill and Slug Control and Countermeasures Plan.

SECTION D: WATER CONSUMPTION:

Type a question

	Source (City, Well, etc.)	Quantity (Estimate for New Facility)
1
2
3

Zero Discharge Permit Application

SECTION D: WATER CONSUMPTION (CONTINUED):

List for the past twelve months water consumption from water bills. (Attach copy of recent water bill or estimate for new facility):

Attach copy of recent water bill or estimate for new facility

Water Bill Account Number

(a) Year for 1st 6-month period

Water consumption - 1st 6-month period

Year for 2nd 6-month period

Water consumption - 2nd 6-month period

Units are in:

gpd100 cfcfOther

If other, please specify

(c) Volume from other sources:

gallons per day

Describe any raw water treatment process in use:

List Water Consumption in Facility:

Cooling Water Gallons Per Day

Boiler Feed Gallons Per Day

Process Water Gallons Per Day

Sanitary System Gallons Per Day

Contained in Product Gallons Per Day

Other (Please Specify) Gallons Per Day

List Water Using Processes in Section D(4) above that will discharge to the sewer system:

Zero Discharge Permit Application

SECTION E: WASTEWATER RECYCLE PROCESSES:

Do any processes recycle and/or reuse water/wastewater streams without discharge to the

YesNo

If yes, indicate which of the following process wastestreams are recycled and/or reused:

SECTION F: SANITARY SEWER AND COMBINED SEWER CONNECTION

1. List plant sewer connections

	Sewer Size (Inches)	Descriptive Location of Sewer Connection and Discharge Point	Average Flow (gpd)
1
2
3

SECTION G: WASTEWATER CONTROL MEASURES:

Are there any methods of water conservation and/or waste recovery programs practiced at

YesNo

If yes, outline methods

2. a. Is any form of pretreatment (see list below) practiced at this facility?

YesNo

If yes, list name(s) of Pretreatment System Operator(s)

b. If yes, list name(s) of Pretreatment System Operator(s)

3. For all wastestreams which are treated, check the appropriate boxes for types of pretreatment used at this facility

Provide any additional descriptive information (include process plans, pretreatment plans, drawings, manufacturer’s information, etc., if available)

4. Does your facility comply with the Narragansett Bay Commission discharge limitations based on recent wastewater analysis? Discharge limitations summarized on page 13 of this application

YesNoDo Not Know

Attach a copy of any wastewater analyses which you may have.

Zero Discharge Permit Application

SECTION G: WASTEWATER CONTROL MEASURES (CONTINUED):

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

SECTION H: CHEMICALS USED AND STORED ON PREMISES:

List all chemicals and solvents presently used or stored at your facility:

	Chemical	Annual Usage
1
2
3
4
5

Are any chemicals or solvents discharged to the sewer system?

YesNo

If yes, please specify:

SECTION I: NON-DISCHARGED WASTES:

Are any waste liquids or sludges removed from facility site?

YesNo

If yes, these may best be described and quantified as:

	Waste Type	Estimated Gallons Per Year
Service Quality
Waste Product
Oil
Grease
Pretreatment Sludge
Inks/Dyes
Thinner
Paints
Acids and Alkalis
Plating Wastes
Pesticides
Other (Please Specify Below)

Other (Please Specify)

Zero Discharge Permit Application

SECTION I: NON-DISCHARGED WASTES (CONTINUED):

Does your company remove the above wastes from the facility?

YesNo

No

If no, state the name(s) and address(es) of all waste haulers:

(a) Name

Address

Permit # (If Applicable)

(b) Name

Address

Permit # (If Applicable)

Are any sludges, liquids, etc. placed with trash for disposal?

YesNo

If yes, describe:

Zero Discharge Permit Application

SECTION J: DESIGNATION OF AUTHORIZED AGENT

I, Type a label , certify that I am the Type a label of Type a label and that Type a label is authorized to make submittals to the Narragansett Bay Commision (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.

ZERO DISCHARGE

PERMIT APPLICATION

RETURN TO:

NARRAGANSETT BAY COMMISSION PRETREATMENT SECTION 2 ERNEST STREET PROVIDENCE, RHODE ISLAND 02905

(401) 461-8848

(401) 461-0170 FAX