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Industrial User QuestionnaireFOR MSD USE ONLY Account Number: TA: TS: Reviewer: Date: Category sIu NSCIU CIU NONTOX TOXIC SURCH NOPROC MULTI SPEC METROPOLITAN ST. LOUIS SEWER DISTRICT DIVISION OF ENVIRONMENTAL COMPLIANCE INDUSTRIAL USER QUESTIONNAIRE Note to Signing Official: In accordance with Title 40 of the Code of Federal Regulations Part 403, Section 403.14, information and data provided in this questionnaire, which identifies the nature and frequency of discharge, shall be available to the public without restriction. Requests for confidential treatment of other information shall be governed by procedures specified in 40 CFR Part 2. Should a discharge permit be required for your facility, the information in this questionnaire will be used to develop the permit. SECTION A - GENERAL INFORMATION 1. Company Name: 2. Mailing Address: 3. Premise Address: City: State Missouri Zip Code City: State Missouri 4. Person Authorized to Sign Reporting Documents (see note after Section H): Name: Title: Zip Code Phone Number 5. Check One: O Existing Discharge O Proposed Discharge If proposed, indicate discharge start date: 6. Shift Information: a. Number of shifts per work day: and work days per week: b. Average number of employees per shift: 1st 2nd 3rd c. Shift start times: SECTION B - PRODUCT OR SERVICE INFORMATION 1st 2nd 3rd HH:MM AM/PM HH:MM AM/PM HH:MM AM/PM Total: 1. Briefly describe the primary manufacturing or service activities at the premise address and list the applicable SIC number for each activity: PRIMARY ACTIVITY SIC NUMBER a. b. c. d. e. f. Ver. 12/2014 Page 1 Company Name: Premise Address: SECTION B - PRODUCT OR SERVICE INFORMATION (Continued) 2. Are primary activities generally batch or continuous processes ? 3. Principal raw materials used: 4. Principal products produced: 0 batch 0 continuous 5. Check all activities which are conducted at your premise in addition to the primary activities described in B.1 above Indicate the SIC number, if known. Do not check activities which are already included in B.1. ACTIVITY (with related 40 CFR Part) SIC NO. ❑ a. Adhesive and Sealants Mfg. ❑ b. Aluminum Forming (467) ❑ c. Asbestos Mfg. (427) ❑ d. Battery Mfg. (461) ❑ e. Carbon Black Mfg. (458) ❑ f. Cement Mfg. (411) [lg. Centralized (non-Haz.) Waste Treatment (437) ❑ h. Coal Mining (434) ❑ i. Coil Coating (465) ❑ j. Concentrated Animal Feeding Operations (412) ❑ k. Concentrated Aquatic Animal Production (451) ❑ I. Copper Forming (468) ❑ m. Dairy Products Processing (405) ❑ n. Drum Reconditioning ❑ o. Electrical and Electronic Components (469) ❑ p. Electroplating (413) ❑ q. Explosives Mfg. (457) ❑ r. Ferroalloy Mfg. (424) ❑ s. Fertilizer Mfg. (418) ❑ t. Food Preparation Liu. Fruit and Vegetable Processing (407) [Iv. General Offices ❑ w. Glass Mfg. (426) [Ix. Grain Milling (406) ❑ y. Gum and Wood Chemical Mfg. (454) ❑ z. Haz. Waste Treatment, Storage or Disposal ❑ aa. Health Care or Hospital (460) ❑ bb. Industrial Laundry ❑ cc. Ink Formulating (447) ❑ dd. Inorganic Chemicals Mfg. (415) ❑ ee. Iron and Steel Mfg. (420) ❑ ff. Leather Tanning and Finishing (425) ❑ gg. Machine Shop ❑ hh. Machinery Mfg. or Rebuilding (438) ❑ ii. Meat Processing (432) ❑ jj. Metal Finishing (433) ❑ kk. Metal Molding and Casting (464) ❑ II. Mineral Mining and Processing (436) ❑ mm. Nonferrous Metals Forming/Metal Powders (471) ACTIVITY (with related 40 CFR Part) SIC NO. ❑ nn. ❑ oo. ❑ pp• ❑ qq• ❑ rr. ❑ ss. ❑ tt. ❑ uu. ❑ vv. ❑ ww. ❑ xx. ❑ YY• ❑ zz. ❑ aaa. ❑ bbb. ❑ ccc. ❑ ddd. ❑ eee. ❑ fff. ❑ ggg. ❑ hhh. ❑ iii. ❑ iii. ❑ kkk. ❑ III. Nonferrous Metals Mfg. (421) Oil and Gas Extraction (435) Ore Mining and Dressing (440) Organic Chem/Plastics/Synthetic Fibers Mfg (414) Paint Formulating (446) Painting, Finishing or Paint Stripping Parts Washing Paving and Roofing Mat'Is (Tars & Asphalt) (443) Pesticide Chem Mfg/Formulating/Packaging (455) Petroleum Refining (419) Pharmaceutical Mfg. (439) Phosphate Mfg. (422) Photographic Processing (459) Plastic Molding and Forming (463) Porcelain Enameling (466) Printing and Publishing Pulp, Paper and Paperboard Mfg. (430) Q.C. Laboratory R & D Laboratory Radioactive Materials Processing Repair Shop, Garage Rubber and Rubber Products Mfg. (428) Seafood Processing (408) Soap and Detergent Mfg. (417) Solvent Recycling ❑ mmm. Steam Electric Power Generation (423) ❑ nnn. ❑ 000. ❑ rir. ❑ qqq. ❑ rrr. ❑ sss. ❑ ttt. ❑ uuu. Sugar Processing (409) Textile Mills (410) Timber Products Mfg. (429) Transportation Equipment Cleaning (442) Transportation Services Used Oil Reclamation Vehicle/Equipment Washing Warehousing ❑ vvv. Waste Combustors (444) ❑ www. Waste Recycling ❑ xxx. Others (Describe) ❑ yyy. Others (Describe) ❑ zzz. Others (Describe) 6. Are your activities subject to seasonal variation? If "Yes," explain and indicate the month(s) of peak activity: 0 Yes 0 No Ver. 12/2014 Page 2 Company Name: Premise Address: SECTION C - WATER CONSUMPTION AND WASTEWATER DISCHARGES 1. Raw Water Source(s): ❑ City of St. Louis Water Div. ❑ Surface water ❑ Missouri American Water Co. ❑ Private well ❑ Other municipal source ❑ Other (describe) ❑ Hauled by contractor 2. Water Bill Addressee: 3. Water Service Account Numbers: 4. List past twelve months water usage from: 1 st 3 mo period through 2nd 3 mo period through 3rd 3 mo period through 4th 3 mo period through Water Bills and Other Sources Total: Ccf = 0 ❑ Water Bills ❑ Other Sources Ccf Ccf Ccf Ccf Ccf Ccf Ccf Ccf GPD-calendar = 0 GPD-work 5. Describe any treatment or conditioning process performed on the raw water before use (list regeneration/reject water volume in 6h below): 6. Identify all water uses within your facility: Water Uses Estimated Average Daily Use (Gal per workday) a. Sanitary b. Irrigation & lawn watering c. Non -contact cooling water d. Contact cooling water e. Process water f. Plant & equipment washdown g. Boiler h. Regeneration/reject water i. Other uses j. Total of USES (6a through 6i ): (6a through 6i must equal total at item 4) 7. Identify all water losses and wastewater discharges from your facility: Water Uses Estimated Average Daily Loss/Discharge (Gal per workday) a. Municipal sewer b. Watercourse, storm drain, surface c. Haulers d. Evaporation e. Contained in product f. Total of LOSSES & DISCHARGES: (7a through 7e must equal total at 6j ) 8. For each activity you listed in Sections B.1 and B.5, list the average water usage and average wastewater discharge per workday. Attach additional sheets, if needed. (Total Avg. Water Use must equal total for 6e) Item Type of Discharge Avg. Water Use Avg. Discharge to Date when activity first No Activity Batch None GPD (GPD) Mun Sewer (GPD)commenced at this facility 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Ver. 12/2014 Page 3 Total: Company Name: Premise Address: SECTION D - SEWER CONNECTION INFORMATION 1. Attach a scale drawing of your premise, which shows (for permit renewals, highlight any changes since last application): a. All buildings, structures, alleys, streets and other pertinent features. b. All sewers and drains, including all connections, inlets, manholes, vents and other access or control structures. Identify each sewer as sanitary, storm or combined and indicate its size. c. A sampling point for each connection to the public sewer. d. A sampling point for each discharge from a federally regulated categorical process. e. A sampling point for each discharge to a separate storm sewer or watercourse. 2. List each sampling point identified in 1 c, d and e above and each connection for which there is no sampling point. Assign a sequential reference number to each location, starting with No. 1. Attach additional sheets, if needed. Reference Sewer Size Description of sewer sampling point or connection. Upstream to other point? Total avg flow per Number (inches) (Vent, manhole, valve, other appurtenance. Indicate size & location) Yes / No List Ref. No. workday(GPD) 1 2 3 4 5 6 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SECTION E - WASTEWATER INFORMATION Grand Total Average Flow per Workday: 0 1. For each point listed in Section D.2 above, list the wastewater discharge corresponding to each water usage listed in Section C.6. Attach additional sheets, if needed. Type of Wastewater Discharge Quantity (GPD-workday) for each sampling point or connection listed in D.2 Facility Total (See instr.) 1 2 3 4 5 6 7 upstream to upstream to upstream to upstream to upstream to upstream to upstream to a. Sanitary c. Non -contact cooling water d. Contact cooling water e. Process ( From C.8 ) 0 0 0 0 0 0 0 f. Plant & equipment washdown g. Boiler blowdown h. Regeneration/reject water i. Other Totals ( Same as D.2 ): 0 0 0 0 0 0 0 2. If any of the above points discharge to a watercourse or to a separate storm sewer, complete the following: NPDES Outfall Number NPDES Permit Number 3. Do any of the above sampling points also convey stormwater from your premise ? 4. Do you pretreat any of the wastes discharged through any of the above points ? 0 0 0 Ver. 12/2014 Page 4 Company Name: Premise Address: SECTION E - WASTEWATER INFORMATION (Continued) 5. Describe '' e the t y e of wastewater er pretreatment ment you employ prior t o each point for which you marked "Yes" in E.4 Ref. No. Pretreatment System Description 6. Does your facility have a written: a. Spill control plan ? b. Waste minimization plan ? 0 Yes 0 No 0 Yes 0 No c. Solvent management plan ? d. Slug discharge control plan ? 0 Yes 0 No 0 Yes 0 No 7. If any wastewater analyses have been performed on the wastewater discharges from your facility attach copies of the most recent data. Be sure to specify the locations from which the samples were collected. Attach sketches, plans, drawings, etc. as necessary. Permit renewal applications, only, may skip this item. 8. Priority Pollutant Information: Check one of the four boxes by each listed chemical to indicate whether it is: "Suspected Absent", "Known Absent", "Suspected Present" or "Known Present" ON YOUR PREMISE. Any chemical which is used in your manufacturing or service activity or is generated as a product or as a by-product should be marked "Known Present." Some pollutants are known by other names. Refer to the instruction booklet for synonyms for those pollutants which have an asterisk (*): SA = "Suspected Absent" KA = "Known Absent" Item No PRIORITY POLLUTANT SA KA SP KP 1. asbestos (fibrous) 2. cyanide (total) 3. antimony (total) 4. arsenic (total) 5. beryllium (total) 6. cadmium (total) 7. chromium (total) 8. copper (total) 9. lead (total) 10. mercury (total) 11. nickel (total) 12. selenium (total) 13. silver (total) 14. thallium (total) 15. zinc (total) 16. acenaphthene 17. acenaphthylene 18. acrolein 19. acrylonitrile 20. aldrin 21. anthracene 22. benzene 23. benzidine 24. benzo (a) anthracene * 25. benzo (a) pyrene 26. benzo (b) fluoranthene 27. benzo (g,h,i) perylene * 28. benzo (k) fluoranthene " 29. alpha-BHC 30. beta-BHC 31. delta-BHC 32. gamma-BHC " 33. bis (2-chloroethyl) ether * 34. bis (2-chloroethoxy) methane * 35. bis (2-chloroisopropyl) ether * Ver. 12/2014 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 O 00 Page 5 SP = "Suspected Present" KP = "Known Present" Item No PRIORITY POLLUTANT SA KA SP KP 36. Reserved 37. bis (2-ethylhexyl) phthalate 38. bromodichloromethane * 39. bromoform * 40. bromomethane * 41. 4-bromophenylphenyl ether 42. butylbenzyl phthalate 43. carbon tetrachlroride * 44. chlordane 45. 4-chloro-3-methylphenol * 46. chlorobenzene 47. chloroethane * 48. 2-chloroethylvinyl ether 49. chloroform * 50. chloromethane " 51. 2-chloronaphthalene 52. 2-chlorophenol * 53. 4-chlorophenylphenyl ether 54. chrysene * 55. 4, 4'-DDD " 56. 4, 4'-DDE " 57. 4, 4'-DDT " 58. dibenzo (a,h) anthracene * 59. dibromochloromethane 60. 1, 2-dichlorobenzene * 61. 1, 3-dichlorobenzene " 62. 1, 4-dichlorobenzene " 63. 3, 3'-dichlorobenzidine 64. Reserved 65. 1, 1-dichloroethane * 66. 1, 2-dichloroethane * 67. 1, 1-dichloroethene * 68. trans-1, 2-dichloroethene " 69. 2, 4-dichlorophenol 70. 1, 2-dichloropropane * O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 Company Name: Premise Address: SECTION E - WASTEWATER INFORMATION (Continued) Priority Pollutant Information (Continued) SA = "Suspected Absent" KA = "Known Absent" Item No PRIORITY POLLUTANT SA KA SP KP 71. (cis and trans) 1, 3-dichloropropene * 72. dieldrin 73. diethylphthalate * 74. 2, 4-dimethylphenol * 75. dimethyl phthalate 76. di-n-butyl phthalate 77. di-n-octyl phthalate * 78. 4, 6-dinitro-2-methylphenol * 79. 2, 4-dinitrophenol 80. 2, 4-dinitrotoluene 81. 2, 6-dinitrotoluene 82. 1, 2-diphenylhydrazine * 83. endosulfan I * 84. endosulfan II* 85. endosulfan sulfate 86. endrin 87. endrin aldehyde 88. ethylbenzene 89. fluoranthene 90. fluorene * 91. heptachlor 92. heptachlor epoxide 93. hexachlorobenzene * 94. hexachlorobutadiene 95. hexachlorocyclopentadiene * 96. hexachloroethane * 97. indeno (1, 2, 3-cd) pyrene * 98. isophorone * 99. methylene chloride * O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 SP = "Suspected Present" KP = "Known Present" Item No PRIORITY POLLUTANT SA KA SP KP 100. naphthalene 101. nitrobenzene 102. 2-nitrophenol 103. 4-nitrophenol * 104. N-nitrosodimethylamine * 105. N-nitrosodi-n-propylamine * 106. N-nitrosodiphenylamine 107. PCB-1016 * 108. PCB-1221 * 109. PCB-1232 110. PCB-1242 * 111. PCB-1248 * 112. PCB-1254 113. PCB-1260 * 114. pentachlorophenol 115. phenanthrene 116. phenol 117. pyrene 118. 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin * 119. 1, 1, 2, 2-tetrachloroethane * 120. tetrachloroethene * 121. toluene * 122. toxaphene 123. 1, 2, 4-trichlorobenzene 124. 1, 1, 1-trichloroethane * 125. 1, 1, 2-trichloroethane * 126. trichloroethene * 127. Reserved 128. 2, 4, 6-trichlorophenol 129. vinyl chloride * O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 O 000 9. For priority pollutants in E.8, which are indicated "Known Present" or "Suspected Present", list and provide the following information for each: (Attach additional sheets, if needed.) Item HOW USED (for KP) ANNUAL LOSS TO No. PRIORITY POLLUTANT or WHY SUSPECTED (for SP) USAGE for KP(lbs) SEWER for KP(lbs) SECTION F - STORM WATER INFORMATION 1. List any industrial storm water (NPDES/MO State Operating) permits issued to this premise. Do not include NPDES permits listed in Section E.2. MDNR MDNR Ver. 12/2014 Page 6 Company Name: Premise Address: SECTION G - NON-SEWERED WASTES 1. Do you generate any liquid wastes or sludges, as described in item 2 below, which are not disposed in the sewer system? O Yes O No If "Yes" complete items 2 and 3 below. Note: Be sure to include wastewaters listed in Section C.7.c. If "No" skip remainder of this section. 2. Information on non-sewered waste: Type of Waste Estimated Quantity Disposed per year Units Store On -Site Dispose On -Site Dispose Off -Site Acids and/or Alkalies ❑ Equipment Oils and/or Grease ❑ Infectious Waste ❑ Inks/ Dyes ❑ Kitchen/Food Service Grease ❑ Organic Compounds ❑ Paints or Paint Sludges ❑ Pesticides ❑ Pretreatment Sludges ❑ Radioactive Waste ❑ Solvents/Thinners ❑ Other ❑ Other ❑ Other 3. List your USEPA and/or MDNR Hazardous Waste generator numbers: USEPA MDNR SECTION H - INDUSTRIAL WASTE SURCHARGE INFORMATION 1. Provide the following analytical information for each sampling point or each connection to the public sewer only if your water usage exceeds 80 Ccf per month (1,995 Gal per calendar day). Representative samples of the wastewater in each sewer must be collected and analyzed for the listed parameters. Report the daily average concentrations in mg/I for each point. Permit renewal applications, only, may skip Section G regardless of water usage volume. Parameter Sewer Reference Numbers (Refer to Section D.2) If more than 7, attach additional sheets 1 2 3 4 5 6 7 Date Sampled Sample Start Time (eg. HH:MM PM) Sample End Time (eg. HH:MM PM) Type of Sample Flow (GPD) Biochemical Oxygen Demand (5 day) Chemical Oxygen Demand Total Suspended Solids Collected By (Name of organization): Analyzed By (Name of organization): Ver. 12/2014 Page 7 Company Name: Premise Address: SECTION I - CERTIFICATION AND SIGNATURE 1. The following individual may be contacted regarding the information contained in this questionnaire: Name of Contact Person: Title: Phone Number 2. "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." Name of Signing Official: Title: Phone Number Signature: Date: This certification, along with any other reporting documents, must be signed by an individual described as follows: a responsible corporate officer if the user is a corporation; a general partner if the user is a partnership; the proprietor if the user is a sole proprietorship; a duly authorized representative of the individual just described, if that individual submits a written authorization which specifies a person or position within the company, having responsibility for the overall operation of the facility from which the discharge originates, such as a plant manager, or overall responsibility for environmental matters at the company. List attachments included with this questionnaire: Ver. 12/2014 Page 8