Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Industrial Waste Survey

    Industrial Waste Survey
    General Industrial Pretreatment Regulations
  2. A. General Information
  3. Type of Process*
  4. B. Industrial Waste
  5. (include domestic sewage if applicable)
  6. Please include pipe size shape, materials, and flow in your response
  7. C. Annual Variation in Operation
  8. Is there a schedule shutdown?
  9. Is production seasonal?
  10. Please use this section to describe periods of either full, limited, or no production.
  11. Water Usage
  12. List Water Consumption in Plant (gpd)
    If not applicable, please type N/A
  13. C.1. Wastewater Information
    If your facility employs processes in any of the 34 industrial categories or business activities listed below, and if and if any of these processes generate wastewater or wastewater sludge, place a check beside the category or business activity (check all that apply).
  14. A. 34 Industrial Categories
  15. B. Other Business Activity
  16. If not listed in categories above, please describe.
  17. C.2. Pretreatment devices or processes used for treating wastewater or sludge
    (check all that apply)
  18. C.3. If any wastewater analyses have been performed on the wastewater discharge(s) from your facilities, attach a copy of the most recent data to this questionnaire. Be sure to include the date of the analysis, name of laboratory performing the analysis, and location(s) from which sample(s) were taken (attach sketches, plans, etc. as necessary).
  19. For upload of analysis, sketches, plans, plats, etc.
  20. C.6. Is this plant, or any process thereof, subject to an existing Federal Categorical Pretreatment Standard?*
  21. C.7. Wastewater Characterics:
    Please indicate the presence of any of the parameters listed below.
  22. Chemical Parameters
  23. C.8. Priority Pollutant Information
    Please indicate by each listed chemical, whether it is "Known to be Present", "Suspected to be Present", "Known to be Absent", or "Suspected to be Absent" in your wastewater discharge. Indicate concentrations if known.
  24. Metals & Inorganics
  25. Phenols & Cresols
  26. Monocyclic Aromatics
  27. PCBs & Related Compounds
  28. Ethers
  29. Nitrosamines & Other Nitrogen-Containing Compounds
  30. Halogenated Aliphatics
  31. Phthalate Esters
  32. Polycyclic Aromatic Hydrocarbons
  33. Pesticides
  34. C.9. ** If you are unable to identify the chemical constituents of products you use that are discharged, or subject to being discharged in your wastewater, attach copies of the Material Safety Data Sheets for such products.
  35. D. Other Waste
  36. D.1. Are any liquid wastes or sludges from this facility disposed of by means other than discharges to the sewer system?
        If “Yes”, complete items D.2. & D.3.
        If “No”, skip remainder of Section D.
      1. D.2. These wastes may best be described as (check all that apply):
      2. D.3. For above marked wastes, does your facility practice:
      3. E – Environmental Control Permits
      4. The information contained in this questionnaire is familiar to me and to the best of my knowledge and belief; such information is true, complete and accurate. I believe that the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and / or imprisonment.
      5. Leave This Blank:

      6. This field is not part of the form submission.