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Commercial/Industrial User Wastewater Survey METROPOLITAN ST. LOUIS SEWER DISTRICT DIVISION OF ENVIRONMENTAL COMPLIANCE 10 East Grand Ave., St. Louis, MO 63147, 314-436-8710 COMMERCIAL/INDUSTRIAL USER WASTEWATER SURVEY 1. MSD P-Reference Number_____________________________ (see instructions) 2. MSD Account Number_________________________________ Telephone Number___________________________ Company Name _____________________________________________________________________________________________ Mailing Address _____________________________________________________________________________________________ _____________________________________________________________________________________________ Premise Address _____________________________________________________________________________________________ _____________________________________________________________________________________________ 3. No. of Employees_____, No. days/week_____, No. shifts/day_____, Peak months_______________________________________ 4. Please check off all items which describe activities at your premise: ___Doctor/Dental Serv. ___Manufacturing ___Product Formulating ___Vehicle Maintenance ___Dry Cleaning ___Offices ___Product Packaging ___Veterinarian ___Health Care Serv. ___Photo/X-Ray Proc. ___Residential ___Warehousing ___Laundromat ___Printing ___Restaurant ___Wholesale Distribution ___Machine Shop ___Product Assembly ___Retail Sales ___Other (describe) ___________________________________________________________________________________________ 5. Provide a brief description of the specific activities performed at this establishment: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 6. Raw materials & chemicals:_____________________________________________________________________________________ Final products/services:_________________________________________________________________________________________ 7. Are other companies located within the same building? Yes___ No___ If yes, list them:_______________________________________________________________________________________________ 8. Do you Use water in any manufacturing process? Yes___ No___ Avg vol/day________________________ Use water for cooling purposes? Yes___ No___ Avg vol/day________________________ Use water in a boiler system? Yes___ No___ Avg vol/day________________________ Use any air pollution devices w/water? Yes___ No___ Avg vol/day________________________ Have any above ground storage tanks? Yes___ No___ #_____ Contents:____________________________________________ ___________________________________________ Have any underground storage tanks? Yes___ No___ #_____ Contents:____________________________________________ ___________________________________________ Use or have on site any oils or grease? Yes___ No___ List:______________________________________________________ Use or have on site any solvents? Yes___ No___ List:______________________________________________________ 9. Do you prepare metal parts for any coating or painting step? Yes___ No___ If yes, is an acid or acid-containing product used? Yes___ No___ List the acid or product used:____________________________________________________________________________________ 10. Do you generate hazardous waste? Yes___ No___ MO hazardous waste generator #______________________________________ If yes, but no HW #, explain:_____________________________________________________________________________________ List hazardous wastes generated:_________________________________________________________________________________ 11.==> ATTACH PLANS AND DRAWINGS AS REQUIRED (see instructions) 12. Information furnished by: Name:_________________________________________________________________________________ Title:________________________________________ Telephone No.______________________________ I certify under penalty of Law that this document and all attachments were prepared under my direction or supervision; and the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. 13. Name and title of signing official:_________________________________________________________________________________ __________________________________________________________________ Telephone No._____________________________ Signature:__________________________________________________________ Date_________________________________3/2007 COMMERCIAL/INDUSTRIAL USER WASTEWATER SURVEY FORM INSTRUCTIONS ► If you have received this survey for completion in conjunction with a request for approval to connect to MSD sewers, please note the following: For Item 1, the MSD Engineering Department assigns a P-reference number for all plans with a connection to MSD sewers. Record this number in the space provided. For a new site, answer the questions based on the operations and conditions which will exist once the new facility is in full operation. For an expansion or modification of an existing site, answer the questions based on the operations and conditions which will exist only for the expanded/modified portion once the expansion/modification is complete. For Item 11, include blueprints and/or schematics as required by the MSD Engineering Department, including interior plumbing plans. ► If you have received this survey as a request for information to update MSD records on industrial activity, please note the following: For a new site, answer the questions based on the operations and conditions which will exist once the new facility is in full operation. For an existing site, answer the questions based on the operations and conditions which currently exist for the entire facility. For Item 11, include any available interior plumbing plans and plans showing where laterals connect to MSD sewers. If these are not available, include a sketch showing the location of all plumbing fixtures, drains, sewer vents and manholes, and any known laterals. General Instructions: Item 1. See top section of instructions. Item 2. Provide the MSD account number shown on your sewer bills. If you have more than one account for this location, list all accounts. Item 3. For peak months, indicate those in which business activity is higher than average. Item 4. These are general activities. Check off all that apply. Item 5. Describe more fully the items checked in Item 4. Item 6. List any raw materials or chemicals which are used or stored at this facility. List also your final products and/or services. Item 7. If you share a building with other companies, list the other occupants. Item 8. Answer all questions fully. Item 9. If you list a brand name, then also include the chemical name. Item 10. If you generate hazardous waste but do not have a generator number or are not required to have one, explain. Item 11. See top section of instructions. Item 12. Self-explanatory. Item 13. A signing official is either: a. a responsible corporate officer if the user is a corporation, b. a general partner if the user is a partnership, c. the proprietor if the user is a sole proprietorship.