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 INFORMATIONCompany NameFacility NameStandard Industrial Classification # (SIC)Business License #Site Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Representative Completing the FormName First Last TitleContact Phone NumberEmail Address Contact in Case of EmergencyName First Last TitlePhoneEmail Address Property OwnerName First Last PhoneEmail 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 EmployeesWater 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)Aluminum FormingBattery ManufacturingBuilders' Paper and Board MillsCarbon Black ManufacturingCoil CoatingCopper FormingElectrical or Electronic ComponentElectroplatingFeedlotFertilizer ManufacturingGlass ManufacturingGrain MillInk FormulatingInorganic Chemical ManufacturingIron and Steel ManufacturingLeather Tanning and FinishingMetal FinishingMetal Molding or CastingNonferrous Metal Forming / Metal PowdersOrganic Chemicals, Plastics & Synthetic Fibers Manuf.Paint FormulatingPaving or Roffing Materials (Tar & Asphalt)Pesticide ChemicalsPetroleum RefiningPharmaceutical MenufacturingPorcelain EnamelingPulp, Paper, or Fiberboard ManufacturingRubber ManfuacturingSoaps or Detergent ManufacturingSteam Electric Power GeneratingTimber Products ProcessingWill 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)AcetoneArsenicBariumBenzeneCadmiumChloroformChromiumCopperCyanideEthyl BenzeneLeadMercuryMethylene ChlorideNIckelPetroleum Based OilsPhenois / PhenolicsSeleniumSilverTolueneXyleneZincWaste Discharge (hold down the CTRL key to select multiple lines)Air Pollution Control EquipmentAnodizingBeverage Bottling / ManufacturingBoil / Cooling BlowdownChemical Etching or MillingCooling Water, ContactCooling Water, Non-ContactDomestic WasteElectroplatingEquipment ManufacturingFertilizer Application ServiceGrain MillFood ProcessingFood Service EstablishmentGroundwater TreatmentLaundryMedical / Dental ServicesMetal Coating (Chromating, Phosphating, etc.)Pesticide Application ServicePhotographic / Film ProcessingPlastic ProcessingPowder CoatingPrinted Circuit Board ManufacturingPrinting and PublishingProcess WaterSlaughter/Meat Packing/RenderingVehicle-Equipment Manufacturing/RepairVehicle or Equipment WashdownWaste RecyclingWater TreatmentWood PreservingWill 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)Amalgam SeparatorAmalgam Chairside TrapGrease Interceptor, Outside CapacityGrease Interceptor, Inside CapacityHair TrapOil / Water SeperatorpH NeutralizerSilver Recovery SystemWhat 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 quantityWill you discharge any RCRA listed or characteristic hazardous wastes to the sanitary sewer? YES NO If Yes, list the quantityDo 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 herePlease upload any additional documentation for sections above. Drop files here or Select files 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)CAPTCHA Alternative:WPA
