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SPARTANBURG SANITARY SEWER DISTRICT INDUSTRIAL PRETREATMENT PROGRAM

INDUSTRIAL/NON-DOMESTIC WASTEWATER SURVEY FORM

SECTION A - GENERAL INFORMATION. 1) Company or business name: _________________________________________________ 2) Mailing address: ___________________________________________________________ Zip code 3) Address of premises: _______________________________________________________ 4) Contact official name: _______________________________________________________

Title

Phone: ( )_____________________ Fax: ( )___________________________ Cell Phone: ( )_______________________ E-mail: ______________________________

Address (if different from above) ______________________________________________

5) Alternate person to contact concerning information provided herein:

________________________________________________________________________

NOTE TO SIGNING OFFICIAL: Any information submitted in this form may be claimed as confidential by the submitter; any such claim must be asserted at the time of submission by writing the phrase "CONFIDENTIAL BUSINESS INFORMATION" on each page containing such information. If no claim of confidentiality is made at the time of submission, the information will be treated in accordance with Federal Regulation 40 CFR 403.14, SCDHEC 61-9 Section 403.14, and Section 1.3.14 within Spartanburg Sanitary Sewer Use Rules and Regulations, which, among other things, states that information describing the submitter's wastewater constituents and characteristics and other effluent data as defined in 40 CFR 2.302 cannot be treated as confidential and shall be available to the public without restriction.

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 gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, 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 that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations

Signature of official: _______________________________ Date: ____________________

Name (Print): _____________________________________Title: ____________________

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6) (a) Type of business conducted (metal plating, meat packing, food processing, textile printing, etc.):

(b) Indicate applicable North American Industry Classification System (NAICS) code

and/or Standard Industrial Classification (SIC) code for all processes. (If more than one applies, list in descending order of importance).

NAICS SIC

Please indicate with an "X" in the blank column prior to the described processes, to document any process production waste stream in your facility subject to National Pretreatment Categorical Standards.

40 CFR 405 Dairy Products 40 CFR 406 Grain Mills 40 CFR 407 Canned & Preserved

Fruits & Vegetables 40 CFR 408 Canned & Preserved

Seafood Processing 40 CFR 409 Sugar Processing 40 CFR 410 Textile Mills 40 CFR 411 Cement Mfg. 40 CFR 412 Feedlots 40 CFR 413 Electroplating 40 CFR 414 Organic Chemicals, Plastics

and Synthetic Fibers 40 CFR 415 Inorganic Chemicals Mfg. 40 CFR 417 Soap & Detergent Mfg. 40 CFR 418 Fertilizer Mfg. 40 CFR 419 Petroleum Refining 40 CFR 420 Iron & Steel Mfg. 40 CFR 421 Nonferrous Metal Mfg. 40 CFR 422 Phosphate Mfg. 40 CFR 423 Steam Electric Power

Generating 40 CFR 424 Ferroally Mfg. 40 CFR 425 Leather Tanning and

Finishing 40 CFR 426 Glass Mfg. 40 CFR 427 Asbestos Mfg. 40 CFR 428 Rubber Mfg. 40 CFR 429 Timber Products Processing 40 CFR 430 The Pulp, Paper, and

Paperboard 40 CFR 432 Meat Products

40 CFR 433 Metal Finishing 40 CFR 434 Coal Mining 40 CFR 435 Oil & Gas Extraction 40 CFR 436 Mineral Mining & Processing 40 CFR 437 Centralized Waste

Treatment 40 CFR 438 Metal Products & Machinery

40 CFR 439 Pharmaceutical Mfg. 40 CFR 440 Ore Mining and Dressing 40 CFR 442 Transportation

Equipment Cleaning 40 CFR 443 Paving and Roofing

Materials ( Tar and Asphalt) 40 CFR 444 Waste Combustors 40 CFR 445 Landfills 40 CFR 446 Paint Formulating 40 CFR 447 Ink Formulating

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40 CFR 450 Construction and Development

40 CFR 451 Concentrated Aquatic Animal Production

40 CFR 454 Gum & Wood Chemicals Mfg.

40 CFR 455 Pesticide Chemicals

40 CFR 457 Explosives Mfg. 40 CFR 458 Carbon Black Mfg. 40 CFR 459 Photographic 40 CFR 460 Hospital 40 CFR 461 Battery Mfg. 40 CFR 463 Plastics Molding & Forming 40 CFR 464 Metal Molding & Casting 40 CFR 465 Coil Coating 40 CFR 466 Porcelain Enameling 40 CFR 467 Aluminum Forming 40 CFR 468 Copper Forming 40 CFR 469 Electrical & Electronic

Components 40 CFR 471 Nonferrous Metal

Forming and Metal Powders Other:

7) Indicate the source(s) of your water supply and the volume of water supplied in either

gallons per day (gpd) or cubic feet per day for a typical working day:

Source Account Number Avg. gallons per day

Avg. cu.ft. per day

Spartanburg Water System

Metropolitan Sub-District B

Other Agency

Private Well

8) Provide your best estimate of water consumption within your plant in gallons per day (gpd)

and indicate if the volume is based on actual measurement, or was estimated:

Type of Water Usage Average Volume of Usage

gallons per day (gpd) Measured = M Estimated = E

Domestic/Sanitary (restrooms, showers, water fountains, canteen)

Process Water (including clean-up)

Cooling Water

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Type of Water Usage Average Volume of Usage gallons per day (gpd)

Measured = M Estimated = E

Boiler Feed Water

Water contained in Product

Irrigation

Other (i.e. waste to ground, stream, etc.

Total Gallons Per Day

9) WASTEWATER DISPOSAL METHOD: (a) Does your company discharge any of the water listed in #8 above to a public sewer system for treatment by the Spartanburg Sanitary Sewer District? ( ) yes, ( ) no. (If no, go to #11, pg. 6). (b) If yes, indicate with an “X” in the section below the disposal method for each type

(refer to #8 above) of water consumption or usage at your facility:

Waste Disposal Method

Public Sewer

Septic Tank

Land Application

NPDES # Other Disposal

Domestic/Sanitary

Process Water

Cooling Water

Boiler Water

Irrigation

Other Water Usage:

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(c)

COOLING WATER Please mark -If any cooling water is discharged to the public sewer system, please check and complete the following information that applies to your system: Cooling water is recycled; system only bleed-off to sewer Cooling water is once-through (not recycled); all system water that is no evaporated is

discharged to sewer Cooling system is for air conditioning/humidification Cooling system is used for machinery Cooling product formulation Cooling for other: List chemicals used, amount and frequency used in cooling water if any: Other than the carrier piping, the cooling water contacts the following, prior to discharge to sewer: Nothing, is non-contact prior to discharge Machine parts Hydraulic, lubricating fluid Product Other wastewater Estimated/Measured volume of discharge to the public sewer during a typical day Gallons of cooler water bleed-off discharged per day _____________GPD Gallons of non-contact cooling water discharged per day ______________GPD Gallons of contact cooling water discharged per day ______________GPD (d)

Boiler Water

Please mark -If any boiler water is discharged to the public sewer system, please check and complete the following information that applies to your system: Excess boiler feed water is discharged directly to sewer. Excess boiler feed water is recycled to make-up tank. Make-up tank over flow is discharged to: Public sewer system Storm water system or ditch/culvert Other: Boiler blowdown is : Automatic Manual operation Discharged to public sewer system Discharged to storm sewer system Discharged to Other: List the chemical(s) added to the boiler water, the amount and frequency: Estimated/Measured volume of discharge to the public sewer during a typical day Gallons of boiler feed/boiler make-up water discharged per day _____________GPD Gallons of boiler blowdown discharged per day ______________GPD

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10) IS ONLY DOMESTIC & SANITARY SEWER AND/OR COOLING WATER AND/OR BOILER WATER DISCHARGED TO THE PUBLIC SEWER SYSTEM FROM YOUR FACILITY? ( ) yes ( ) no

IF YES, COMPLETE THIS QUESTION AND THE PRECEDING QUESTIONS ON PAGES 1 - 5 OF THIS QUESTIONNAIRE, INCLUDING THE REQUIRED SIGNATURE ON PAGE 1, AND RETURN ONLY THESE PAGES TO THE SPARTANBURG SANITARY SEWER DISTRICT.

IF NO, MEANING OTHER TYPES OF WATER ARE DISCHARGED FROM YOUR FACILITY TO THE PUBLIC SEWER SYSTEM, COMPLETE THE ENTIRE QUESTIONNAIRE, INCLUDING THE REST OF THIS QUESTION AND THE REQUIRED SIGNATURE ON PAGE 1, AND RETURN ALL PAGES TO THE SPARTANBURG SANITARY SEWER DISTRICT.

(a) Do you have a grease trap on-line at your facility?

___ yes ___no. If yes, how many? ____

(b) If yes, does this grease trap serve a food preparation area at your facility? ___ yes ___ no.

(c) Approximately how often is this grease trap pumped out?

___________________________________________________________________

(d) When was the last time it was pumped? __________________________________ By whom? __________________________________________________________ Where is it taken for disposal? __________________________________________

11) IF NO WATER OF ANY TYPE IS DISCHARGED TO A PUBLIC SEWER SYSTEM,

INDICATE BELOW HOW WASTEWATER DISPOSAL IS MADE AND RETURN PAGES 1 - 6 OF THIS QUESTIONNAIRE WITH ALL APPLICABLE INFORMATION COMPLETED (INCLUDING THE SIGNATURE OF PAGE 1) TO THE SPARTANBURG SANITARY SEWER DISTRICT.

Wastewater disposal other than public sewer system Yes No On-site disposal to septic tank On-site disposal to treatment and then receiving stream. If yes please provide the NPDES #_________________

Other disposal (land application, off-site disposal , please provide:

NOTE: IF YOU HAVE QUESTIONS CONCERNING THIS SURVEY FORM, PLEASE

CONTACT INDUSTRIAL PRETREATMENT PROGRAM at (864) 582-3250.

MAILING ADDRESS: Spartanburg Sanitary Sewer District

P.O. Box 251 Spartanburg, SC 29304

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SECTION B - PRODUCT OR SERVICE INFORMATION 1) Give a brief description of the primary manufacturing or service activity on the premises:

________________________________________________________________________ ________________________________________________________________________

2) Check or list all additional support activities conducted at your premises that have

not been reported as primary production or service activities in Section A, please indicate with an “X”

Machine Shop, repair shop Vehicle washing and/or servicing Laboratory Printing Photographic processing Electroplating Garage Finishing, Painting Engine or Vehicle steam cleaning Cafeteria Other:

3) List each wet manufacturing process or other support activity that contributes to the wastewater

discharge from your premises and provide NAICS No. or SIC Code, when applicable, and provide the requested flow data for each wet process or activity (Attach additional sheets if necessary):

List Wet Process/Wet Activities NAICS No. /SIC Code Estimated/Measured

Flow and Frequency Ex. Clean-up finishing machines

2261cotten woven finishing

1500 gallons once per week

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4) List the principal compounds (use generic names) used in your operation and indicate

whether each is a raw material or catalyst/intermediate or indicate other use; please provide the estimated quantities used (Attach additional sheets if necessary):

Note: As supplemental information to this Table, copies of applicable Material Safety Data Sheets may also be submitted as attachments; but not in lieu of providing the information requested in #4 above.

5) Please complete the following listing of pollutants of interest. For each pollutant please check whether it is known to be present, suspected to be present, or known to be absent in your operation. Suitable responses should be based on the following descriptions:

Known to be present: The compound has been detected in the wastewater discharge by reasonable lab analytical procedures or by reference (i.e. from supplier or literature) is known to be present in the raw materials or product and in the wastewater discharge.

Suspected to be present: The compound is either a raw material in the processes employed or is a product, a by-product, catalyst, etc. Its presence in the wastewater discharge is, therefore, a reasonable technical judgement.

Known to be absent: The application of reasonable analytical procedures designed to detect the material have yielded negative results.

Principle Compounds Used

Raw Materials/Process Chemicals

Catalyst/Intermediate Other use Estimate Qty. Used per Working Day in lbs/day or gallons

per day

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Chemical Name

Present at

Facility

Quantity Present

at Facility

Absent at Facility

Present in Discharge to POTW

Suspected Present in Discharge to POTW

Concentration in Discharge,

(mg/l)

Absent in Discharge to POTW

Metals and Inorganics Antimony (Total) Arsenic Asbestos Beryllium Cadmium Chromium (Hexavalent) Chromium (Total) Copper Cyanide Lead Mercury Nickel Selenium Silver Thallium Zinc

Phenols and Cresols Phenol Phenol, 2-chloro Phenol, 2,4-dichloro Phenol, 2,4,6-trichloro

Phenol, pentachloro Phenol, 2-nitro Phenol, 4-nitro (ortho-nitro)

Phenol, 2,4-dinitro Phenol, 2,4-dimethyl o-Cresol, 4,6-dinitro(4,6-dinitro- 2-methylphenol)

Monocyclic Aromatic (excluding Phenols, Cresols, and Phthalates) Benzene Benzene, chloro Benzene, 1,2-dichloro (ortho-dichloro)

Benzene, 1,3-dichloro (meta-dichloro)

Benzene, 1,4-dichloro(para-dichloro)

Benzene, 1,2,4-trichloro

Benzene, hexachloro (perchloro)

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Chemical Name

Present at

Facility

Quantity Present

at Facility

Absent at Facility

Present in Discharge to POTW

Suspected Present in Discharge to POTW

Concentration in Discharge,

(mg/l)

Absent in Discharge to POTW

Benzene, ethyl Benzene, nitro Toluene Toluene, 2,4-dinitro Toluene, 2,6-dinitro

PCB's and Related Compounds PCB-1016 PCB-1221 PCB-1232 PCB-1242 PCB-1248 PCB-1254 PCB-1260 2-Chloronaphthalene

Ethers Ether, bis chloromethyl Ether, bis 2-chloroethyl Ether, bis 2-chloropropyl Ether, 2-chloroethyl vinyl Ether, 4-bromophenyl phenyl

Ether, 4-chlorophenyl phenyl

Bis (2-chloroethoxy) methane

Nitrosamines and Other Nitrogen Containing Compounds

Nitrosamine, dimethyl Nitrosamine, diphenyl N-nitroso-di-n-propylamine

Benzidine Benzidine, 3,3'dichloro Hydrazine, 1,2-diphenyl (hydrazobenzene)

Acrylonitrile Halogenated Aliphatics

Methane, bromo Methane, chloro-(methyl chloride)

Methane, dichloro Methane, chlorodibromo Methane, dichlorobromo Methane, tribromo

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Chemical Name

Present at

Facility

Quantity Present

at Facility

Absent at Facility

Present in Discharge to POTW

Suspected Present in Discharge to POTW

Concentration in Discharge,

(mg/l)

Absent in Discharge to POTW

Methane, trichloro (chloroform)

Methane, tetrachloro (carbon tetrachloride, carbon tet.)

Methane, trichlorofluoro (fluorocarbon - 11)

Methane, dichlorodifluoro (fluorocarbon 12)

Ethane, chloro (ethylchloride)

Ethane, 1, 1-dichloro (ethylidene chloride)

Ethane, 1, 2-dichloro Ethane, 1,1,1-trichloro Ethane, 1,1,2-trichloro (vinyl trichloride)

Ethane, 1,1,2, 2-tetrachloro (acetylene tetrachloride)

Ethane, hexachloro (perchloro, perc)

Ethene (ethylene), chloro (vinyl chloride)

Ethene (ethylene), 1,1-dichloro

Ethene (ethylene), trans-dichloro

Trichloroethene (ethylene)

Tetrachloroethene (ethylene) Propane, 1,2-dichloro (propylene dichloride)

Propene, 1,3-dichloro (1,3 dichloropropylene)

Hexachlorobutadiene

Hexachlorocyclopentadiene

Phthalate Esters Phthalate, di-o-methyl

Phthalate, di-n-ethyl

Phthalate, di-n-butyl

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Chemical Name

Present at

Facility

Quantity Present

at Facility

Absent at Facility

Present in Discharge to POTW

Suspected Present in Discharge to POTW

Concentration in Discharge,

(mg/l)

Absent in Discharge to POTW

Phthalate, di-n-octyl Phthalate, bis 2-ethylhexyl

Phthalate, butyl benzyl Polycyclic Aromatic Hydrocarbons

Acenaphthene Acenaphthylene Benzo (a) anthracene Benzo (b) fluoranthene Benzo (k) fluoranthene Benzo (ghi) perylene Benzo (a) pyrene Chrysene Dibenzo (a,n,) anthracene (1,2,5,6 dibenzanthra- cene)

Fluoranthene Fluorene Indeno (1,2,3-cd) Pyrene

Naphthalene Phenanthrene Pyrene Anthracene Acrolein Aldrin BHC Alpha BHC Beta BHC Gamma (Lindane) BHC Delta Chlordane DDD DDE DDT Dieldrin Endosulfan Alpha Endosulfan Beta Endosulfan Sulfate Endrin Endrin aldehyde Heptachlor Heptachlor expoxide Isophorone TCDD (Dioxin)

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Chemical Name

Present at

Facility

Quantity Present

at Facility

Absent at Facility

Present in Discharge to POTW

Suspected Present in Discharge to POTW

Concentration in Discharge,

(mg/l)

Absent in Discharge to POTW

Toxaphene Surfactants

Alkylphenol Ethoxylates Nonylphenol Ethoxylates Others (identify)

6) For any of the Pollutants of Interest which you have indicated as Known To Be Present in

the preceding Table, please (a) provide the following information concerning the source or location of this compound in your operation and (b) provide your best estimate of the quantity of each Pollutant of Interest discharged to the public sewer (indicate units if different from lbs./day). Attach additional sheets if necessary.

POLLUTANTS OF INTEREST KNOWN TO BE PRESENT

TABLE Chemical Name

Process or Source of Compound

Estimated Discharged to Public Sewer (lbs/day)

Ex. Toluene Cleaning 0.0015 lbs/day

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7) (a) If laboratory data is available that would characterize the wastewater in terms of concentrations of the following basic parameters, please provide this information along with any other parameters that characterize the wastewater (example: titanium concentration = 8 mg/l). If the concentrations are estimated, please indicate in the second column.

Wastewater Characteristics From Laboratory Analyses Frequency &

Number of Analyses

Parameter Average Concentration

(mg/l)

Measured = M Estimated = E

concentration(mg/l)

Sample Type Grab Comp.

BOD5 TSS COD Grease & Oil

NH3-N pH Temp. Others:

(b) Source of laboratory analyses results included above:

_____ in-house lab _____ SSSD lab _____ commercial lab___________________________________(Name)

NOTE: Copies of lab analyses results can be attached as supplemental data, but not in lieu of completing the above. SECTION C - PLANT OPERATIONAL CHARACTERISTICS 1) In the following two tables, list all major processes at your facility with a wet discharge to

public sewer as continuous or batch and provide the other related data. Continuous discharge - means having wastewater flow during all or almost all of the time during which the process is in operation.

Batch discharge - means having a wastewater discharge in discrete intervals at which time all or almost all of the wastewater is dumped.

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Table I Continuous Wet Process

Process Description NAICS No. SIC Code Average Volume

Wastewater Discharge Rate (gal/min)

Ex. Glue Formulation 2643 1,800 2 gpm

(Attach other sheets if needed)

Table II Batch Wet Process

Process Description NAICS No. SIC Code Avg. Volume Avg. Rate (gal/min)

Frequency

Ex. Dyeing 313312 2 gpm 2/week Sat., Wed

(Attach other sheets if needed)

*NOTE: PLEASE INDICATE THE DAY(S) IF A DISCHARGE USUALLY OCCURS ON THE SAME DAY(S) OF THE WEEK (INCLUDING WEEKENDS).

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2) List any processes subject to seasonal variation: __________________________________

________________________________________________________________________ Indicate month(s) of peak operation and production: _______________________________

________________________________________________________________________

Indicate any month(s) of low seasonal production: _________________________________

________________________________________________________________________ 3) Is there a scheduled shutdown (i.e. for clean-up purposes or for July 4th week?)

___ yes, ___ no.

If yes, when_______________________________________________________________

4) Shift information (based on full production):

(a) Number of production shifts per workday ______ for approximately _____ months per year.

(b) Number of work days per week _____ for approximately_____ months per year.

(c) Average number of employees per shift:

First ________ non-production/ Second _____ (office/admin.) __________ Third _______ TOTAL Employees_______

(d)

Operational Times Shifts are based on : 8 hours; 10 hours; 12 hours; 24 hours Start Time a.m. pm End Time a.m. p.m. Ex. 8:00 a.m. 4:00 p.m. 1st shift 2nd shift 3rd shift

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5) (a)

Clean-Up In Operations Is clean-up occurring during: Time of the day Days of week

A portion of the shift Specified clean-up shift Specified day of week

(b) Explain what is cleaned (i.e. machines cleaned, vat cleaned) and what type of cleaners (i.e. alkaline or acid) are used? _________________________________________________________________________________________________________________________________________________________________________________________________________

6) Discharge to the public sewer system:

(a) How many days per week does your plant discharge wastewater that is ultimately treated by the Sewer District? Process wastewater ____ days Domestic/Sanitary wastewater ____ days

(b) How many hours per day does your plant discharge process wastewater? _____

hours.

(c) List below the approximate percent of your total daily wastewater discharge that occurs during each shift:

First Shift _____% Second Shift _____% Third Shift _____%

Clean-up Shift ____% (Explain, if necessary) _______________________________

___________________________________________________________________

7) (a) How many points of connection (or points of discharge) to the public

sewer system does your facility have? ___________________________________________________________________ ___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________

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(b) Provide a sketch (schematic) to show each connection or discharge point location relative to your facility. Please identify street(s) and buildings in the sketch such that these connection point locations could be generally located in the field. Number each connection point in the sketch and indicate in the Table below whether the wastewater at that point from your facility is domestic only, or process only, or combined. Attach a separate sheet for sketch.

Connections to Public Sewer No. Connection Location (Refer to Sketch) Type of Wastewater discharged at this location Domestic

Only Process Only Combined

1. 2 3. 4. 5.

8) Does your company have a designated sampling manhole or flow monitoring station that

can be used by the Sewer District for obtaining a representative sample of your process wastewater discharge? ___ yes ___ no. If yes, indicate where and on which line connecting to public sewer that this sampling point is located in the sketch in 7b. above.

9) Does your company have a wastewater flow monitoring system approved by the

Sewer District from which readings are obtained for user charge and/or surcharge billings? ____ yes ____ no.

If yes, provide the following information:

(a) Meter Type and brand _________________________________________________

(i.e. Ultrasonic/Isco, Float/Stevens) (b) Recorder Brand______________________________________________________

(c) Recorder Chart Type ___________________(i.e. strip or circular; 7-day,

30 day, etc.) (d) Flow Control Point

1. Flume type (shape) ______________(i.e. Parshal) 2. Weir Type (shape) ______________(i.e. 22-1/2° v-notch)

(e) Date of most recent calibration__________________________________________ (f ) Name of calibration company ___________________________________________

10) Are any laboratory monitoring and analyses conducted on your process wastewater

discharge? ___ yes ___ no.

If yes, check all applicable:

___on a scheduled basis ___by outside commercial lab ___by in-house equipment and personnel

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11) Has your plant instituted any in-plant controls to reduce water pollution? ____ yes ____ no. Please indicate those applicable:

____ water recycle ____ water reuse ____ chemical substitutions ____ material reclamation

____ other: ________________ 12) Are any process changes or plant expansions planned during the next three

years? ___ yes ___ no.

If yes, briefly describe the proposed change and what changes can be expected in the wastewater discharge. _______________________________________________________________________

________________________________________________________________________

________________________________________________________________________

SECTION D - WASTEWATER VOLUMES, PRETREATMENT AND SLUDGE 1) Provide in the table below your best estimate of the breakdown of the average volume of Wastewater discharge from your operation and the average volume of water losses:

Type of Discharge or Loss (Not to Public Sewer)

Average Volume Gallons per Day Measured = M Estimated = E

Sewer leading to on-site treatment

1. Treatment facility NPDES #________________

2. Septic Tank

Storm sewer not tied to public sewer system or on-site treatment system

Boiler Evaporation

Cooling Tower Evaporation

Waste Haulers Name:

Contained in Product

Other

TOTAL DISCHARGE NOT TO POTW

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Type of Discharge or Loss to public sewer system

Average Volume Gallons per Day Measured = M Estimated = E

Domestic/Sanitary (restrooms, showers, cafeterias, etc.)

Process Wastewater

Contact Cooling Water

Non-Contact Cooling Water

Boiler Blowdown

Other

TOTAL DISCHARGE TO PUBLIC SEWER SYSTEM

2) Please indicate with an “X” any pretreatment devices or processes used at your facility on the wastewater prior to its being discharged to the public sewer system:

Grease Trap Filtration Grease or Oil Separation Centrifuge Grit Removal Screening Flow Equalization Reverse Osmosis Flow Equalization with Aeration Ozonation Chemical precipitation Chlorination Settling Basins Carbon Filtration Biological treatment Solvent Separation Clarifiers Dissolved Air Floatation (DAF) pH adjustment manual feed pH adjustment automated feed pH adjustment with acid pH adjustment with base Cyanide Destruct Chlorination or other Disinfection Septic Tank Silver Recovery Defoaming Agents Deodorizers Other:

Indicate "X" here if NO pretreatment is provided____.

3) If you have plans for installation of pretreatment units, please describe the units and the

schedule for installation.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

(a) Please provide a schematic flow diagram of the pretreatment units at your plant; label each unit process (i.e. pH adjustment; filtration); also indicate at which

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point any planned pretreatment units would be placed on the flow diagram. Attach a separate sheet for schematic.

(b) Does the South Carolina Department of Health & Environmental Control require a

certified operator be responsible for your pretreatment system? ___ yes ___ no.

If yes, what level of certification is required? ___A-Bio, ___B-Bio, ___C-Bio, ___D-Bio.

___A-PC, ___B-PC, ___C-PC, ___D-PC

(c) Who is the person currently responsible for your pretreatment system? __________________________________________________________________

What is their certification number? _______________________________________

4) Does the wastewater discharged from any process waste stream at your facility:

Description Yes No If yes, please explain

Create a fire or explosion hazardous?

Have pH lower than 5.0 standard units?

Contain a substance that can obstruct the flow in the collection system

5) Are any sludges or liquid wastes (i.e. acids, alkalies, heavy metal sludges, inks, dyes, oil,

grease, organic compounds, paints, pesticides, plating waste) generated at your facility which are not discharged to the sewer leading to the Sewer District? ___ yes ___ no If yes, complete the following table:

Offsite Waste Disposal

Waste/Sludge Description

Estimated Annual Quantity Generated (Units)

Non-Hazardous= NH Hazardous = H

Waste Haulers name, EPA ID# and address

Disposal Facility Name, EPA ID#, and address

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Offsite Waste Disposal Waste/Sludge Description

Estimated Annual Quantity Generated (Units)

Non-Hazardous= NH Hazardous = H

Waste Haulers name, EPA ID# and address

Disposal Facility Name, EPA ID#, and address

(a) Is this facility a hazardous waste generator? ___ yes, ___ no

If yes please indicate which type: ( ) small quantity generator; ( ) large quantity generator; ( ) conditionally exempt.

Facility’s EPA Hazardous Waste Generation ID# ____________________________ (b) Is a Spill Prevention Control and Countermeasure Plan prepared for your facility? ___ yes ___no.

(c) If yes, is notification of the Sewer District included in your plan? ___ yes ___ no.

(d) Please list the materials stored or produced at your facility which are considered in

your Spill Prevention Control and Countermeasure Plan: ________________________________________________________________

________________________________________________________________

(e) If no, and if materials are stored or produced at your facility which, through accidental spills or through seepage could enter sewer lines leading to the public sewer system, please contact the Industrial Pretreatment Program at (864) 582-3250, to discuss the District’s notification information to be established for your operations. Survey.form.doc 3/9/2012