Wastewater Discharge Application

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Please correct the field(s) marked in red below:

Section I: General Information
1
Date
 *
2
Is this a new application or a renewal?
 *
Is this a new application or a renewal?
Please Enter the Facility Site Information Below
3
Business Name
 *
4
Physical Address
 *
5
Mailing Address
 *
6
Business Phone Number
 *

Please enter the Signatory Official Information Below (Click here for signatory requirements)

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Signatory First & Last Name
 *
8
Signatory Title
 *
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Business Telephone Number
 *
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Business Address
 *
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Zip Code
 *
Enter Local Contact (if different from Signatory Official)
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First & Last Name
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Title
14
Business Telephone Number
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Business Address
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Zip Code
Section II: Description of Activities
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Type (please check all that apply)
 *
Type (please check all that apply)
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Standard Industrial Classification Code(s) (SIC). Please list all that apply. This code can be found on your Employers' Quarterly Report
 *
19
Are you manufacturer?
 *
Are you manufacturer?
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Attachment B: Do you participate in any of the following manufacturing processes?
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Attachment B: Do you participate in any of the following manufacturing processes?
Yes No
Aluminum Forming
Asbestos Manufacturing
Battery Manufacturing
Canned and Preserved Fruits and Vegetables
Canned and Preserved Seafood
Carbon Black
Cement Manufacturing
Centralized Waste Treatment
Coal Mining
Coil Coating
Copper Forming
Dairy Products
Electric and Electronic Components
Electroplating
Feedlots
Ferroalloy
Fertilizers
Glass Manufacturing
Grain Mills
Gum and Wood Chemicals
Hospital
Ink Formulating
Inorganic Chemicals
Iron and Steel
Landfills
Leather Tanning and Finishing
Meat Processing
Metal Finishing
Metal Molding and Casting
Mineral Mining and Processing
Nonferrous Metals Forming and Metal Powder
Nonferrous Metals
Oil and Gas Extraction
Ore Mining and Dressing
Organic Chemical, Plastics, and Synthetic Fibers
Paint Formulating
Paving and Roofing Material
Pesticide Chemicals
Petroleum Refining
Pharmaceutical
Phosphate
Photographic
Plastics Molding and Forming
Porcelain and Enameling
Pulp, Paper and Paperboard
Rubber Manufacturing
Soap and Detergent
Steam Electric Power Generation
Sugar Processing
Textile Mills
Timber Products Processing
Transportation Equipment Cleaning
Waste Combustors
Section III: Facility Data / Property Information
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Utility Account Location #
 *
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Customer #
 *
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Name on Utilities Account
 *
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Address on Utilities Account
 *
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Do you own or lease the property?
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Do you own or lease the property?
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If leasing, name of property owner
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Days & Hours of Operation
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Days & Hours of Operation
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Is your facility located outside the City limits?
 *
Is your facility located outside the City limits?
29
Number of employees and/or people on site
 *
Section IV: Water Usage
30
Source of Water (please check all that apply)
 *
Source of Water (please check all that apply)
Total Water Consumption (gallons per day / gpd)
31

Volume of City water used per day
Calculate as follows: gallons on utility bill x 1000 divided by days of use

 *
32
Water Well or Other
Water Well or Other
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Total Combined Daily Water Consumption (gpd)
34
Estimated Water Usage if not yet open (gpd)
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Water Consumption (E=estimated; M=measured)
Gallons Per Day Estimated/Measured
Contact Cooling
Non-contact Cooling
Boiler Feed
Process
Sanitary
Air Pollution Equipment
Contained in Product
Plant/Equipment Washdown
Lawn Irrigation
Other
36
Total Water Usage in gpd (gallons per day)
 *
37
Wastewater Flows (E=estimated; M=measured)
Wastewater Flows (E=estimated; M=measured)
Gallons Per Day Estimated/Measured Discharged to Sewer System
Cool Tower Blowdown
Cooling Water
Boiler Blowdown
Process
Sanitary
Air Pollution Equipment
Cleaning
Plant/Equipment Washdown
Backwash (Filters)
Other
38
Total Discharge to Sewer System in gpd (gallons per day)
 *
Section V: Wastewater Discharge Information
39
Location of Discharge (check all that apply)
 *
Location of Discharge (check all that apply)
If you are not connected to City Wastewater Collection system, go to Section VII.
40
Time of Discharge
 *
Time of Discharge
41
Flow type
 *
Flow type
42
Plumbing connections to the wastewater collection system. List all types (e.g. floor drains, sinks, restrooms, etc.). Please provide blueprint or map, if possible.
 *
Plumbing connections to the wastewater collection system. List all types (e.g. floor drains, sinks, restrooms, etc.). Please provide blueprint or map, if possible.
43
List the size and location of all discharge sewer lines which connect to the City wastewater collection system. (Provide map if possible).
List the size and location of all discharge sewer lines which connect to the City wastewater collection system. (Provide map if possible).
44
Is a sampling portal located on the sewer line? (minimum of a 4" 2-way clean-out).
 *
Is a sampling portal located on the sewer line? (minimum of a 4" 2-way clean-out).
45
Does storm water or roof runoff discharge to the wastewater collection system through any connection?
 *
Does storm water or roof runoff discharge to the wastewater collection system through any connection?
46
Section VI: Pretreatment Information (please note all that apply)
Size Location
Food grease trap (pot type)
food grease trap (submerged)
Enzyme injection
Sand/lint trap
Acid trap
Silver recalimer
pH control
Other (describe)
None
Section VII: Facility Site Information
47
Cleaning Solutions
Lbs or Gals Location
Caustic/jet vat
Solvent vat
Acid vat
48
 
Please Describe Lbs or Gals Location
Other Cleaning Solutions
49
Waste Oil
Lbs or Gals Location
Waste Oil Filters
Machine Coolants
Paint Wastes/Filters
Waste Antifreeze
Asbestos/PCB/Radioactive
Waste Grease (fryolator)
50
 
Please Describe Lbs or Gals Location
Other Waste Oil
51
Bulk Material Storage (above or below ground)
Size Location
Fuel tank
Non-hazardous material
Hazardous waste
Waste oil
Chemical blending tanks
Waste Grease (fryolator)
52
 
Please Describe Size Location
Other Bulk Material Storage
53
Please provide a Material Safety Data Sheet (MSDS) for each chemical stored in bulk onsite in quantities greater than five (5) gallons and chemicals discharged to the wastewater collection system.
54
Has this facility developed a Spill Control Plan to prevent the discharge of chemicals onsite to the wastewater collection system?
 *
Has this facility developed a Spill Control Plan to prevent the discharge of chemicals onsite to the wastewater collection system?
Section VIII: Disposal Methods
55
Please provide documentation (e.g. manifests, waste receipts, etc.) concerning offsite disposal of all wastes or other than trash. (Include Waste Type, Transporter and Location)
Please provide documentation (e.g. manifests, waste receipts, etc.) concerning offsite disposal of all wastes or other than trash. (Include Waste Type, Transporter and Location)
56
Has any of the wastes generated at this site been previously analyzed or classified as a hazardous waste?
 *
Has any of the wastes generated at this site been previously analyzed or classified as a hazardous waste?
57

If yes, please provide a copy of the classification and/or analytical results?

NOTE: 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 EPA Regional Waste Management Division Director, and the 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.

58
Does this facility have:
Does this facility have:
Yes (Provide Number) No
Texas Solid Waste Number
US EPA Registration Number
59
If applicable, provide a copy of the Texas or EPA correspondence issuing the number.
Section IX: Pollution Prevention Activities
60
Please list all pollution prevention activities you have incorporated or plant to incorporate into your business operations in the three (3) years.
 *
Section X: Compliance with Ordinance Requirements
61
To the best of my knowledge, the discharges from this facility will meet the requirements of the Sewage Quality Control Ordinance, No. 93-75 as amended. 
 *
To the best of my knowledge, the discharges from this facility will meet the requirements of the Sewage Quality Control Ordinance, No. 93-75 as amended.
62

Authorized Representative Statement:

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.

 *
Authorized Representative Statement: 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.

Important Notice:

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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