HomeMy Public PortalAboutIndustrial 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