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3 Industrial Loop Drive - Hannibal, MO - (573) 221-8050

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The Hannibal Board of Public Works will hold a Special Board Meeting on Tuesday, November 26, 2024 at 4:00PM in the HBPW Conference Center to discuss the 2MW Hannibal Airport Solar Project, the 5MW Purchase Power Agreement from Solar, and the Bear Creek Dam Outfall Maintenance Project.

Non-Domestic Industrial User Survey

Home » Non-Domestic Industrial User Survey

The survey must be completed and appropriately signed. This form must be signed by a corporate officer or manager per 40 CFR 403.12(1).

GENERAL INFORMATION

Company Name

Facility Name

Standard Industrial Classification # (SIC)

Business License #

Site Address

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Representative Completing the Form

Name

First Last

Title

Contact Phone Number

Email Address

Contact in Case of Emergency

Name

First Last

Title

Phone

Email Address

Property Owner

Name

First Last

Phone

Email Address

Will / Is the building connected to the public sewer system?

YES

NO

Is Facility connected to the HBPW potable water system?

YES

NO

If Yes, does facility have an approved backflow device?

YES

NO

Location and size of all approved backflow devices: (Attach additional pages if necessary at the end of the survey)

Describe in detail the type of business activity conducted at this site. Include primary products or services:

Construction date(s) for building(s) at this site (if known):

MM slash DD slash YYYY

Starting date for your business at this site

MM slash DD slash YYYY

Normal Operating Schedule: (Actual TImes and Days of the Week)

Total Number of Employees

Water consumption (gallons/month)

Wastewater volume generated (gallons/month)

Is this facility a categorical industry as defined by 40 CFR 403 through 40 CFR 71?

YES

NO

UNKNOWN

Select the appropriate category below (hold down the CTRL key to select multiple lines)

Will ou use EPA Toxics Release Inventory (TRI) chemicals in reportable quantities?

YES

NO

Identify the above chemicals and quantities used (attach additional sheets if necessary):

Will your site have an irrigation or drinking water well?

YES

NO

Will your site have any underground injection control facilities (UIC's such as drywells, drill holes, or drainage pipe galleries)?

YES

NO

Will you store chemicals at your facility in a volume greater than 5 gallons each?

YES

NO

If yes, give description of contents, container size and type, storage location, frequency and method of container cleaning. Indicate if buried metal containers have cathodic protection.

Has your company ever been issued a local, state, or federal environmental permit?

YES

NO

If yes, list the permit(s):

Does this facility use products that contain any of the following items listed below? Select all that are present. Product verification should be accomplished by product label and MSDS. (hold down the CTRL key to select multiple lines)

Waste Discharge (hold down the CTRL key to select multiple lines)

Will you use fats, oils, grease (cooking or petroleum), or dairy products in your business?

YES

NO

Will there be a garage disposal unit (food grinder) at your business?

YES

NO

If Yes, what is the estimated quantiy of waste daily?

Will there be an inteceptor, separator, or other device installed to pretreat your wastewater prior to discharge?

YES

NO

If Yes, select all that apply (hold down the CTRL key to select multiple lines)

What is the normal frequency of maintenance from the pretreatment device?

What is the method of Disposal of all materials collected via pretreatment process and pretreatment device maintenance?

Will you generate hazardous waste as defined by the Missouri DNR and Federal regulations (RCRA)?

YES

NO

If Yes, list the quantity

Will you discharge any RCRA listed or characteristic hazardous wastes to the sanitary sewer?

YES

NO

If Yes, list the quantity

Do you have any accidental spill prevention document to prevent spills or chemicals or sludge discharges from entering the City's sanitary sewer or storm systems? If so, please attach at the end.

YES

NO

Provide any additional comments or explanations here

Please upload any additional documentation for sections above.

Drop files here or

Max. file size: 30 MB, Max. files: 6.

"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered the information submitted. Based on my inquiry of the person of persons who manage the system, or those persons directly responsible for gathering the information. Based on my inquiry of the person or persons who manage the sytem, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations."

Printed Name(Required)

First Last

Title(Required)

Phone(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

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3 Industrial Loop Drive
PO Box 1589
Hannibal, MO 63401

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