Laundries, Laundromats, Dry Cleaners

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.

Laundries/Laundromats/Dry Cleaners Permit Application

WASTEWATER DISCHARGE PERMIT APPLICATION

SECTION A: GENERAL INFORMATION – Check all that apply:

Proposed DischargeExisting Discharge

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, please provide the name and address of the property owner below:

Property Owner’s Name

7a. Designate Company Organization:

Sole ProprietorshipCorporationPartnership

If the company organization is designated as a corporation, then section 7(b) must be completed:

7b. A Corporation under the laws of Type a label , composed of officers as follows:

President's Name

President's Home Address

President's Home Phone

Vice President's Name

Vice President's Home Address

Vice President's Home Phone

Secretary's Name

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.

Laundries/Laundromats/Dry Cleaners Permit Application

SECTION A: GENERAL INFORMATION (CONTINUED):

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.

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

Laundries/Laundromats/Dry Cleaners Permit Application

SECTION A: GENERAL INFORMATION (CONTINUED):

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

Company Seal (If Applicable)

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.

SECTION B: FACILITY OPERATIONAL INFORMATION

Number of washing machines at facility?

What size? (Capacity in pounds)

How many pounds of laundry are washed per day?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Laundries/Laundromats/Dry Cleaners Permit Application

SECTION B: FACILITY OPERATIONAL INFORMATION (CONTINUED):

List all sources of water (city, well, etc:)

	Source	Quantity Used Daily (Estimate for New Facilities)
1
2
3

List Water Bill Account Number

Water Meter Serial Number

Attach copy of most recent water bill

Are there any methods of water conservation practiced your facility?

YesNo

If yes, please explain:

Is this facility an industrial/commercial laundry or a coin-operated laundry?

If industrial/commercia laundry, are any of the following items cleaned at your facility?

How are solids removed from the water?

Lint TrapsSettling Pits

Is any sludge generated?

YesNo

If yes, how is raw sludge disposed of?

Laundries/Laundromats/Dry Cleaners Permit Application

SECTION B: FACILITY OPERATIONAL INFORMATION (CONTINUED):

What is the temperature of your effluent?

Are there any heat exchange systems used?

YesNo

Are there any dry cleaning operations at this facility?

YesNo

If yes, what solvent is used for dry cleaning operations?

Is dry cleaning solvent reclaimed on site?

YesNo

If yes, describe the solvent reclamation procedure

Is any cooling water used for the dry cleaning process?

YesNo

If yes, please explain

Is a solvent/water separator located on the dry cleaning unit?

YesNo

If yes, detail where the solvent and water streams discharge

Does your facility have a boiler room?

YesNo

If yes, what type of fuel is utilized?

If yes, list all discharges from the boiler room. (Blowdown, condensate, etc.)

	Wastewater Source	Gallons Per Day Discharged
1
2
3
4

Any floor drains, discharge, sumps, or open sewer connections located in the boiler room?

YesNo

Laundries/Laundromats/Dry Cleaners Permit Application

SECTION C: 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 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.

WASTEWATER DISCHARGE

PERMIT APPLICATION

LAUNDRIES / LAUNDROMATS

DRYCLEANERS

RETURN TO:

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

(401) 461-8848

(401) 461-0170 FAX

Normal Hours of Operation