WASTEWATER DISCHARGE

WASTEWATER DISCHARGE PERMIT APPLICATION INDUSTRIAL/COMMERCIAL LAUNDRY
PERMIT APPLICATION
INDUSTRIAL/COMMERCIAL LAUNDRY
RETURN TO:
NARRAGANSETT BAY COMMISSION PRETREATMENT SECTION 2 ERNEST STREET PROVIDENCE, RHODE ISLAND 02905
Industrial/Commercial Laundry Permit Application

WASTEWATER DISCHARGE PERMIT APPLICATION
Section A: General Information
Proposed Discharge
Existing Discharge
Recycle Process Operation(s) With No Discharges
Recycle Process Operation(s) With Discharges
Standard Industrial Classification Code(s) (SIC)
Company Name
Facility Mailing Address
NAICS Code
Facility Premise Address
Business Phone Number
Format: (000) 000-0000.
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
Industrial/Commercial Laundry Permit Application

SECTION A: GENERAL INFORMATION (CONTINUED):
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
Format: (000) 000-0000.
Vice President's Name
Vice President's Home Address
Vice President's Home Phone
Format: (000) 000-0000.
Secretary's Name
Secretary's Home Address
Secretary's Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Treasurer's Name
Treasurer's Home Address
Treasurer's Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Enter the Name, Title and Home Address of company owner(s) if sole proprietorship or partnership
1. Name
1. Title
1. Home Address
1. Home Telephone
Format: (000) 000-0000.
2. Name
2. Title
2. Home Address
2. Home Telephone
Format: (000) 000-0000.
3. Name
3. Title
3. Home Address
3. Home Telephone
Format: (000) 000-0000.
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
Format: (000) 000-0000.
2. Name
2. Title
2. Home Address
2. Home Phone
Format: (000) 000-0000.
Date

MonthDayYear
Date
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.
Company Seal (If Applicable)

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SECTION A: GENERAL INFORMATION: (Cont.)

Type a question

Rows	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
Principle Product or Service
Describe All Water Using Processes
Type of Discharge

BatchContinuous
If batch, average number of batches per 24 hours
Industrial/Commercial Laundry Permit Application

SECTION C: FACILITY OPERATIONAL CHARACTERISTICS (CONTINUED):

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

YesNo
If yes, indicate weeks of normal shutdown. When?
Is production seasonal?

YesNo
If yes, explain indicating month(s) of peak production
Average Number of Employees on 1st Shift
Average Number of Employees on 2nd Shift
Average Number of Employees on 3rd Shift
Shift Start Time for 1st Shift
Shift Start Time for 2nd Shift
Shift Start Time for 3rd Shift
If there are any special shifts, please list them here:
Indicate with check mark for each shift normally worked each day:

Type a question

Rows	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
1st Shift
2nd Shift
3rd Shift

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

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If yes, attach a copy of the facility Spill and Slug Control and Countermeasures Plan.
Is this facility an industrial/commercial laundry or coin operatied laundromat
If industrial/commercial laundry, are any of the following items cleaned at your facility:

Oily RagsShop RagsRestaurant LinensUniformsCarpets/RugsOther
Industrial/Commercial Laundry Permit Application

SECTION C: FACILITY OPERATIONAL CHARACTERISTICS (CONTINUED):
Number of washing machines at facility?
What size? (Capacity in pounds)
How many pounds of laundry are washed per day?
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(s) 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 in the dry cleaning process?

YesNo
If yes, please describe
Is a solvent/water separator located on the dry cleaning unit?

YesNo
If yes, detail where the solvent and water streams discharge

Quantity (Estimate for New Facility) in Gallons Per Day:

Rows	Source (City, Well, etc)	Quantity (Estimate for new facility) in Gallons Per Day
1
2
3

Industrial/Commercial Laundry 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):

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Water Bill Account Number
(a) 1st 6 month period, 20
Water Consumption for 1st 6 month period
(b) 2nd 6 month period, 20
Water Consumption for 2nd 6 month period
Type a question

GPD100 CFCFOther
(c) Volume from other sources: gallons per day
Describe any raw water treatment process in use:
List Water Consumption in Facility in Gallons Per Day:
Cooling Water
Boiler Feed
Process Water
Sanitary System
Contained in Product
Other (Please Specify)
Detail all other water using operations:

List Plant and Sewer connections

Rows	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

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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.

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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.

Rows	Water Using Operations	Gallons per day Discharged
1
2
3

Industrial/Commercial Laundry Permit Application

SECTION F: WASTEWATER DISCHARGES, CHARACTERISTICS AND CONTROL
a. Is any form of pretreatment (see list below) practiced at this facility?

YesNo
b. If yes, list name(s) of Pretreatment System Operator(s)
Other, Please Specify
Provide any additional descriptive information (include process plans, pretreatment plans, drawings, manufacturer’s information, etc., if available):
Industrial/Commercial Laundry Permit Application

SECTION F: WASTEWATER DISCHARGES, CHARACTERISTICS AND CONTROL
Does your facility comply with the Narragansett Bay Commission discharge limitations based on recent wastewater analysis? (Discharge standards can be found on the final page of the application pdf)

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

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If No or Do Not Know, indicate steps and time schedule that will be followed in order to
SECTION G: CHEMICALS USED AND STORED ON PREMISES

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

Rows	Chemical	Annual Usage
1.
2.
3.
4.
5.

2. Are any chemicals or solvents discharged to the sewer system?

YesNo
If yes, please specify
Industrial/Commercial Laundry Permit Application
Does your facility have a boiler room?

YesNo
If Yes, list type of fuel(s) utilized in facility boiler room:

If the facility has a boiler room, list all discharges from the boiler room (i.e, blowdown, condensate, etc)

Rows	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
If yes, please answer questions (a) - (f)
(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.

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Are any waste liquids or sludges removed from facility site?

YesNo

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

Rows	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)

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 (if applicable):
(a) Name
(a) Address
Permit #
(b) Name
Address
Permit #
Are any sludges, liquids, etc. placed with trash for disposal?

YesNo
Describe
SECTION K: DESIGNATION OF AUTHORIZED AGENT
I, Name , 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.

Rows	Type of Pretreatment	Wastestream Treated
Oil Separation
Grease Trap
Sedimentation
Filtration
Chemical Addition
Neutralization/pH Adjustment
Biological
Equalization
Recovery
Gasoline Trap
Ion Exchange
Other

WASTEWATER DISCHARGE PERMIT APPLICATION INDUSTRIAL/COMMERCIAL LAUNDRY

PERMIT APPLICATION

INDUSTRIAL/COMMERCIAL LAUNDRY

RETURN TO:

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

Section A: General Information

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

SECTION G: CHEMICALS USED AND STORED ON PREMISES