Heavy Commercial and Industrial Process Wastewater Discharges

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.

Wastewater Discharge Permit Application Long Form

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)

2. Company Name

Facility Mailing Address

Facility Premise Address

Business Phone Number

Date Company Established at Premise Address

Date

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

7a. Designate Company Organization:

Sole ProprietorshipCorporationPartnership

NAICS

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

Wastewater Discharge Permit Application Long Form

SECTION A: GENERAL INFORMATION (CONTINUED):

7b. 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'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.

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.

Wastewater Discharge Permit Application Long Form

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

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.

Wastewater Discharge Permit Application Long Form

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

Type of Discharge

BatchContinuous

Wastewater Discharge Permit Application Long Form

SECTION C: PLANT OPERATIONAL CHARACTERISTICS (CONTINUED):

If batch, average number of batches per 24 hours

Is there a regularly scheduled shutdown for vacation or other purposes?

YesNo

If yes, indicate weeks of normal shutdown. When?

Is production seasonal?

YesNo

If yes, explain indicating month(s) of peak production

Shift Information

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

If there are any special shifts, please list them here

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

Indicate with check mark for each shift normally worked day

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

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

YesNo

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

SECTION D: WATER CONSUMPTION:

Quantity (Estimate for New Facility):

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

Wastewater Discharge Permit Application Long Form

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) 1st 6 month period, 20

Water consumption - 1st 6-month period

Water consumption - 2nd 6-month period

Year - 2nd 6-month period

Units are in

gpd100 cfcfOther

(c) Volume from other sources: in gallons per day

Describe any raw water treatment process in use:

List Water Consumption in Facility:

	Gallons Per Day
Cooling Water
Boiler Feed
Process Water
Sanitary System
Contained in Product
Other (Please Specify)

Detail all other water using operations:

Wastewater Discharge Permit Application Long Form

SECTION E: SANITARY SEWER AND COMBINED SEWER CONNECTION

List plant sewer connections (assign a squenctial connection number to each sewer connection starting with No. 1)

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

If more than three, attach additional connection information

Attach a drawing of the industrial complex showing location of sewers referenced above. Show location of possible sampling points for sewers and SIC process effluents. For reference and field orientation, buildings, streets, alleys and other pertinent physical structures should be included.

SECTION F: WASTEWATER DISCHARGES, CHARACTERISTICS AND CONTROL

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

YesNo

If yes, outline methods:

List all water using processes and indicate which wastewater streams ultimately discharge into the sewer system.

	Water Using Operation	Gallons Per Day Discharged
1
2
3

Wastewater Discharge Permit Application Long Form

SECTION F: WASTEWATER DISCHARGES, CHARACTERISTICS AND CONTROL

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

YesNo

b. If yes, list name of Pretreatment System Operator

For all wastestreams which are treated before discharge, check the appropriate boxes for type of pretreatment used at this facility and indicate the wastestream treated:

	Used at Location	Waste Stream Treated
Oil Separation
Grease Trap
Sedimentation
Filtration
Chemical Addition
Neutralization/pH Adjustment
Biological
Equalization
Recovery
Gasoline Trap
Ion Exchange
Other (Please Specify)

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

Wastewater Discharge Permit Application Long Form

SECTION F: WASTEWATER DISCHARGES, CHARACTERISTICS AND CONTROL

Does your facility comply with the Narragansett Bay Commission based on recent wastewater analysis?

YesNoDo Not Know

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

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

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

	Chemical	Annual Usage
1
2
3
4
5
6

Are any chemicals or solvents discharged to the sewer system?

YesNo

If yes, please specify

Wastewater Discharge Permit Application Long Form

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 Source	Gallons Per Day Discharged
1
2
3

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

YesNo

Are any cooling towers in operation?

YesNo

(a) How many cooling towers are there?

(b) What is the tonnage of each cooling tower?

(c) What is the volume (gallons per day) discharged to the sewer as bleed off from the tower?

(d) Are the towers batch discharged to the sewer?

If so, indicate frequency.

(e) Is there a sample port on the discharge line from the cooling tower?

(f) List all chemicals used in the water treatment for each cooling tower and attach a copy of the Material Safety Data Sheet (MSDS) for each chemical.

Attach a copy of the Material Safety Data Sheet (MSDS) for each chemical.

Wastewater Discharge Permit Application Long Form

SECTION J: NON-DISCHARGED WASTES:

Are any waste liquids or sludges removed from facility site?

YesNo

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

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

Does your company remove the above wastes from the facility?

YesNo

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

(a) Name

(a) Address

(a) Permit #

(b) Name

(b) Address

(b) Permit #

Wastewater Discharge Permit Application Long Form

SECTION J: NON-DISCHARGED WASTES (CONTINUED):

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

YesNo

Describe:

SECTION K: 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.

Attach any additional information relevant to this application

WASTEWATER DISCHARGE PERMIT APPLICATION LONG FORM

PERMIT APPLICATION

LONG FORM

RETURN TO:

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

(401) 461-8848

(401) 461-0170 FAX

Sole Proprietor Contacts