Restaurant and Food

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, ext. 490.

Restaurant & Food Preparation Establishments Permit Application

WASTEWATER DISCHARGE PERMIT APPLICATION

SECTION A: GENERAL INFORMATION:

Discharge

NewExisting

1b. New sewer connection required?

YesNo

1c. For existing facilities with existing discharges, will flow increase by 20% or more?

YesNo

2.Company Name

Facility Mailing Address

Facility Premise Address

Business Phone Number

Business Email Address

example@example.com

Does the company own or rent the facility? If Rented , provide thename and the address of the property owner below:

Property Owner’s Name

Property Owner’s Address

Designate Company Organization:

Sole ProprietorshipCorporationPartnershipLLC

A business established under the laws of Type a label , composed of officers as follows:

1. Name

1. Title

1. Home Address

1. Home Phone

Please enter a valid phone number.

1. Email Address

example@example.com

2. Name

2. Title

2. Home Address

2. Home Phone

Please enter a valid phone number.

2. Email Address

example@example.com

3. Name

3. Title

3. Home Address

3. Email Address

example@example.com

4. Name

4. Title

4. Home Address

4. Home Phone

4. Email Address

example@example.com

SECTION A: GENERAL INFORMATION (CONTINUED):

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

1. Name

1. Title

3. Home Phone

Please enter a valid phone number.

1. Home Address

1. Home Phone

Please enter a valid phone number.

1. Email Address

example@example.com

2. Name

2. Title

2. Home Address

2. Home Phone

Please enter a valid phone number.

2. Email Address

example@example.com

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

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

SECTION A: GENERAL INFORMATION (CONTINUED):

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.

Restaurant & Food Preparation Establishments Permit Application 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.

SECTION B: FACILITY OPERATIONAL INFORMATION:

Seating capacity (per Fire Department Regulation)

Seating capacity (Actual Count)

Normal Hours of Food Preparation/Service:

Monday

Wednesday

Friday

Saturday

Sunday

3. Kitchen Fixtures:

Fixture:

	Yes	No	How Many?
Fryolators
Wok Station
Soup Kettles
Three Bay Sinks
Pre-Rinse Station
Dishwasher
Garbage Disposal
Vegetable Prep Sink
Exhaust Hoods
Other

Other

How are exhaust hoods cleaned?

In Three Bay SinkAutomatic Cleaning SystemSent Off-Site

4.Attach sketch of kitchen showing location and drain lines for all equipment detailed in question 3 above. Grease removal unit must be included on sketch, if applicable.

5.Attach a menu of the foods prepared and served at the facility.

Restaurant & Food Preparation Establishments Permit Application

SECTION B: FACILITY OPERATIONAL INFORMATION:

Does this establishment have an installed and working grease removal unit (GRU)?

YesNo

List Type of Grease Removal Unit

Size

Manufacturer

IndoorOutdoorAutomaticPassive

SECTION C: WATER USE INFORMATION:

Water use data (attach copy of recent water bill or estimate if new facility):

Attach copy of recent water bill or estimate if new facility

Water Supply Account Number

WASTEWATER DISCHARGE

PERMIT APPLICATION

RESTAURANT

FOOD PREPARATION

ESTABLISHMENTS

RETURN TO:

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

(401) 461-8848

(401) 461-0170 FAX

PLEASE PRINT OR TYPE