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City of ChandlerWastewater DischargeQuestionnaire & Permit ApplicationPlease complete this Questionnaire to the best of your ability. If an answer is uncertain, estimate or state that theanswer is unknown. If you have more than one facility location in Chandler, complete a Questionnaire for eachlocation. Use additional sheets if necessary.If you have any questions or problems completing this Questionnaire, contact the Wastewater Quality Division at480-782-3720. Please return this Questionnaire to:City Use OnlyCity of ChandlerIndustrial Pretreatment ProgramPermit NOT RequiredMail Stop 396, PO Box 4008SIU PermitChandler, AZ 85244-4008NewRenewalPART 1 – Industrial User InformationPlease type or print:A.Business InformationBusiness Name:Legal Business Name:Business Owner:Mailing Address:Facility Name:Facility Address:Facility Contact / Title:Phone:Title:Email:Authorized Rep.:Phone:Title:Email:An Authorized Representative is the principal executive officer of at least the level of Vice President of acorporation; a general partner or proprietor of a partnership or proprietorship, or a duly authorized representativeof the individuals designated above.Note to Signing Authorized Representative:I certify under penalty of law that this document and all attachments were prepared under my direction orsupervision in accordance with a system designed to assure that qualified personnel properly gather and evaluatethe information submitted. Based on my inquiry of the person or persons who manage the system, or thosepersons directly responsible for gathering the information, the information submitted is, to the best of myknowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submittingfalse information, including the possibility of fine and imprisonment for knowing violations.Signature of Authorized Representative (seal, if applicable)DateRevision 09, 2019-08-20Page 1 of 7
Wastewater DischargeQuestionnaire & Permit ApplicationB.Property InformationProperty Name:Property Address:Property Owner / Leasing Agent:Mailing Address:Phone:C.Email:Service InformationType of Business:Operations Start Date:Brief description of ALL processes and production rates:Raw materials used:Standard Industrial Classification (SIC) Code(s) for all activities (see Appendix A):D.Operational / Facility InformationNumber of Building(s):Shift Description(s):1Hours:Days:Avg Employees:2Hours:Days:Avg Employees:3Hours:Days:Avg Employees:Total Employees:PART 2 – Industrial CategorizationA.Water & Wastewater InformationIs water used in the manufacturing, production, or industrial processes?Water Sources (check all that apply):PublicPrivateYESNOOther:List all water account numbers:Revision 09, 2019-08-20Page 2 of 7
Wastewater DischargeQuestionnaire & Permit ApplicationList facility water consumption (Daily average on 12 months or best engineered estimates):Non-contact cooling watergallons per dayBoiler feed, water softener regen, R/O rejectgallons per dayProduction operationsgallons per daySanitary (domestic)gallons per dayContained in productgallons per dayLandscape / Other:gallons per dayTotalgallons per dayDoes the wastewater discharged to the sewer contain following:Any amount of fats, oils, or grease (no matter how minute?YESNOAny non-domestic wastes from a commercial or industrial process?YESNODoes any of the production processes generate unused liquid product, (e.g.,bad batches, production over runs, etc.)?YESNOIf YES describe the process, product, average volume, rate of occurrence, disposal method:Are any roof drains or water catchment basins connected to the sewer?YESNOAre sewers from bathrooms and production areas separated?YESNOTotal number of drains in the production area(s):If your business is a restaurant, number of seats:Wastewater discharge characterization:BatchContinuousIntermittentIf batch, describe average frequency of batch discharges per day and average volume:Provide a Water Balance Diagram (see Appendix B for example) [ required]:B.ATTACHEDWastewater TreatmentAre any of the wastewaters discharged to the sewer treated?YESNODoes the facility have any of the following wastewater treatment devices:Grease interceptorGrease trapSand / oil interceptorShared interceptorSolids interceptorAmalgam separatorLint trapAcid neutralizationIon ExchangeFiltrationStrainers / screensSilver recoveryReverse osmosisClarifierEvaporatorCyanide destructWater reuseFilter pressPrecipitation / flocculationOther:Revision 09, 2019-08-20Page 3 of 7
Wastewater DischargeQuestionnaire & Permit ApplicationList the name, address, and phone for any hazardous and non-hazardous waste haulers that you use:C.D.Provide schematics for each device with flow paths [ required]:ATTACHEDProvide a Facility Layout identifying the locations of drains, storm sewers, drywells, wastewater treatment systems, etc. [required]:ATTACHEDPollution PreventionDoes the facility have an accidental spill prevention and control plan?YESNODoes the facility have a pollution prevention plan?YESNODoes the facility have any waste reduction procedures?YESNODoes the facility have any water reuse procedures?YESNODoes the facility have a Toxic Organic or Solvent Management plan?YESNOIf YES to any above, provide a copies of each with this application [ required]:ATTACHEDAnalytical DataHas the facility conducted any wastewater monitoring and testing at the currentor a previously location?Has the facility any wastewater monitoring reports from similar facility that maybe representative of this facility’s wastewater discharge?If YES to any above, provide a copies of the analytical reports with thisapplication [required]:YESNOYESNOATTACHEDRevision 09, 2019-08-20Page 4 of 7
Wastewater DischargeQuestionnaire & Permit ApplicationKnownPresentSuspectedPresentChemical opane(cis & trans) n-octylphthalate4, 6-dinitro- 2,6-dinitrotoluene1,2-diphenylhydrazineendosulfan Iendosulfan IIendosulfan sulfateendrinendrin heptachlor orocyclopentadienehexachloroethaneindeno (1,2,3-cd) pyreneisophoronemethylene p-dioxin1,1 phene1,2,4-trichorobenzene1,1, ene2,4,6-trichlorophenolvinyl Chemical Compoundasbestos (fibrous)cyanide (total)antimony (total)arsenic (total)beryllium (total)cadmium (total)chromium (total)copper (total)lead (total)mercury (total)nickel (total)selenium (total)silver (total)thallium (total)zinc rilealdrinasbesto anthracenebenzenebenzidinebenzo (a) anthracenebenzo (b) pyrenebenzo (b) fluoranthenebenzo (g,h,i) perylenebenzo (k) fluoranthenea-BHC (alpha)b-BHC (beta)d-BHC (delta)g-BHC (gamma)bis (2-chloroethyl) etherbis (2-chloroethoxy) methanebis (2-chloroisopropyl) etherbis (2-ethylyhexyl) 4-bromophenylphenyl etherbutylbenzylphthalatecarbon obenzenechloroethane2-chloroethylvinyl hlorophenol4-chlorophenylphenyl etherchrysene4,4'-DDD4,4'-DDE4,4'-DDTdibenzo (a,h) 85960616263KnownAbsentPriority Pollutant InformationPlease indicate by placing an “X” by each chemical listed, if it is “Suspected to be Absent”, “Known to beAbsent”, “Suspected to be Present”, or “Known to be Present” in your manufacturing or service activityor generated as a by-product.SuspectedAbsentE.Revision 09, 2019-08-20Page 5 of 7
Wastewater DischargeQuestionnaire & Permit ApplicationSIC endix ATable of General Standard Industrial Classification (SIC) Code GroupingsDescription of IndustryBuilding construction, general contractors and operative buildersMeat, grain, dairy processing, bakeries and beverage manufacturingTobacco products manufacturingTextile mill products manufacturingCut and sew apparel manufacturing and similar products made from fabricsLogging, lumber and wood productsFurniture and fixturesPrinting, publishing and allied industriesIndustrial, chemical manufacturing and pharmaceuticalsPetroleum refining and asphalt manufacturingRubber and plastics products manufacturingLeather tanning and products manufacturingStone, clay, glass and concrete products manufacturingSteel works, blast furnaces, foundries, nonferrous metal products manufacturingFabricated metal productsManufacturing of industrial and commercial machineryElectrical and electronic equipment and components manufacturing, except computer equipmentManufacturing of motor vehicles and components, aircraft engine components and boatsManufacturing of instruments and measurement devicesJewelry manufacturingPaging, cellular and other wireless telecommunicationsWholesale trades - durable goodsPrinting and office supplies, wholesale trade - nondurableRetail trade building suppliesRetail sales, general merchandiseRetail grocery salesNew and used vehicle dealers, gasoline stations with convenience storesClothing, shoe storesHome furniture and furnishings, auto parts storesFull-service restaurants, cafeterias, drinking places and fast food restaurantsTobacco, pharmacy, beer, wine and liquor salesBanks and financial institutionsInsurance servicesApartmentsHotels and motelsDry-cleaning, laundry, barber and beauty salon servicesFuneral services and cemeteriesAutomotive repair services, carwashesMiscellaneous repair servicesMotion picture theater, video tape rentalsBowling centers, golf courses, amusement parks, rec. CentersMedical offices, hospitals and nursing homesOffices of lawyersSchools and universitiesChild daycare, elderly care centerChurches, fraternal organizationsEngineering, architectural, surveying, testing servicesVeterinarian servicesMiscellaneous repair servicesRevision 09, 2019-08-20Page 6 of 7
Wastewater DischargeQuestionnaire & Permit ApplicationAppendix BWater Balance Diagram ExampleRevision 09, 2019-08-20Page 7 of 7
answer is unknown. If you have more than one facility location in Chandler, complete a Questionnaire for each location. Use additional sheets if necessary. If you have any questions or problems completing this Questionnaire, contact the Wastewater Quality Division at 480-782-3720. Please return this Questionnaire to: City of Chandler City Use Only
