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Enter Local Contact information if different from Signatory Official
Please list all that apply. This code can be found on your Employers' Quarterly Report
Please check all that apply.
In Gallons Per Day (GPD)
Calculate as follows: Gallons on Utility Bill, times 1,000, divided by Days of Use
Check all that apply:
List all types (e.g. floor drains, sinks, restrooms, etc.)
Please provide blueprint or map, if possible.
Provide map if possible.
Minimum of a 4 Inch, 2-Way Clean-out
Please provide a Material Safety Data Sheet for each chemical stored in bulk on-site in quantities greater than 5 gallons and chemicals discharged to the wastewater collection system.
Include Waste Type, Transporter and Location
If you are discharging or requesting discharge of a hazardous waste ad defined by 40 CFR Part 261 to the wastewater collection system, you must notify the City of Odessa Pretreatment Division, the Environmental Protection Agency (EPA) Regional Waste Management Division Director, and the Texas Commission on Environmental Quality (TCEQ) Hazardous Waste Authority. this notification must include the name of the hazardous waste as set forth in 40 CFR Part 261, the EPA hazardous waste number, and the type of discharge (e.g. continuous, batch, etc). If you discharge more than 100 kilograms of the waste during a calendar month, you must contact the Pretreatment Division for additional reporting requirements and restrictions.
I certify under penalty of law that his document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or person who manage the system or those persons directly responsible for gathering the information, the information 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/or imprisonment for knowing violations.
The information provided in this application, other information submitted by your company, and information gathered by the City in conjunction with the operations and discharges from your company are subject to Open Records Requests. If any of the information submitted by your company is designated as confidential as defined by Section 552.110 of the Texas Public Information Act, you must assert it as such at the time of submission. Each page containing confidential information must be marked "Confidential Business Information". This information, if it is determined that it meets the criteria of the Texas Public Information Act, will be handled in accordance with the procedures described in the Act. If no claim of confidentiality is made at the time of submission, the information will be made available to the public without further notice.
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