PERMIT APPLICATION FORM

Section A - General Information
Facility Address
Facility Address
Mailing Address
Mailing Address
Designated Signatory Authority of the Facility
Designated Signatory Authority of the Facility
Designated Signatory Authority Address
Designated Signatory Authority Address
Designated Signatory Authority Phone
Designated Signatory Authority Phone
Designated Facility Contact
Designated Facility Contact
Designated Facility Contact Phone
Designated Facility Contact Phone
SECTION B – BUSINESS ACTIVITY
Business Activity
If your facility employs or will be employing processes in any of the industrial categories or business activities listed below (regardless of whether they generate wastewater, waste sludge, or hazardous wastes), place a check beside the category of business activity (check all that apply).
Give a brief description of all operations at this facility including primary products or services.
Indicate applicable Standard Industrial Classification (SIC) for all processes (If more than one applies, list in descending order of importance)
Section C - Water Supply
List average water usage on premises (New facilities may estimate):
SECTION D – SEWER INFORMATION
For an existing business:
Will you be occupying an existing vacant building (such as in an industrial park)?
SECTION E – WASTEWATER DISCHARGE INFORMATION
Yes -if the answer to the question is “yes”, complete the remainder of the application. No -if the answer to this question is “no”, skip to section H.
Provide the follow information on wastewater flow rate. (New facilities may estimate)
Hours/day discharged (e.g., 8 hours/day) or hours of discharge (e.g., 9 a.m. to 5 p.m.
Number of batch discharges per day:
(Days of week)
gallons/minute.
Facilities that checked activities in question 1 of Section B are considered Categorical Industrial Users and should skip to next section
List average wastewater discharge, maximum discharge, and type of discharge (batch, continuous, or both), for each plant process. Include the reference number from the process schematic that corresponds to each process. (New facilities should provide estimates for each discharge).
For Categorical Users: Provide the wastewater discharge flows for each of your REGULATED processes or proposed processes. (New facilities should provide estimates for each discharge). Average Flow (GPD), Maximum Flow (GPD), Type of Discharge (batch, continuous, none)
For Categorical Users: Provide the wastewater discharge flows for each of your UNREGULATED processes or proposed processes. (New facilities should provide estimates for each discharge). Average Flow (GPD), Maximum Flow (GPD), Type of Discharge (batch, continuous, none)
Maximum Flow (GPD) & Type of Discharge (batch, continuous, none)
For Categorical Users subject to Total Toxic Organic (TTO) requirements:
If "No", skip next question
SECTION F – TREATMENT
Treatment devices or processes used or proposed for treating wastewater or sludge
(check as many as appropriate)
Treatment Operator
Treatment Operator
Treatment Operator
Treatment Operator
Full or part time?
SECTION G – FACILITY OPERATIONAL CHARACTERISTICS
Number of shifts per work day
First
Second
Third
First
Second
Third
If 'No', Seasonal – check the months of the year during which the business activity occurs
SECTION H – SPILL PREVENTION
If yes, where do they discharge to?
If you have chemical storage containers, bins, or ponds in manufacturing area, could an accidental spill lead to a discharge to: (check all that apply)
SECTION I – NON-DISCHARGED WASTES
If 'Yes', describe
Waste generated, quantity per year, disposal method
Name, address and permit number
AUTHORIZED REPRESENTATIVE STATEMENT
AUTHORIZED REPRESENTATIVE STATEMENT
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Phone 3
Phone 3
Date
Date
By entering your name you agree to the terms of Central Weber's Application verification.