HomeMy Public PortalAboutCommercial-Industrial User Wastewater Short Questionnaire
METROPOLITAN ST. LOUIS SEWER DISTRICT
DIVISION OF ENVIRONMENTAL COMPLIANCE
10 East Grand Ave., St. Louis, MO 63147, 314-436-8710
COMMERCIAL/INDUSTRIAL USER WASTEWATER SHORT QUESTIONNAIRE
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_________________________________1/2021
COMMERCIAL/INDUSTRIAL USER WASTEWATER SHORT QUESTIONNAIRE
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 a s 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 activ ity 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.