Industrial Waste Survey

3780 South 1550 West St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Industrial Waste Survey
Directions for Completing the Industrial Waste Survey Form

1. The St. George Water Reclamation Facility requires certain information from all businesses that discharge wastewater to its wastewater treatment plant.

2. Please complete this Industrial Waste Survey form. Answer all questions as completely as possible. If you do not know the answer to a question, write "Unknown" in the box. If an answer is not applicable to your facility, write "N/A".

3. Failure to complete and submit the Industrial Waste Survey form is a violation of the SGRWRF Pretreatment Ordinance.

4. Please type or print legibly.

5. If you have any questions, please contact the SGRWRF Pretreatment Department at: (435) 627-4266.
Company Name (or dba):*
Permit No. (if applicable)*
Physical Street Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Representative's Name:*
Title:
Phone Number:*

Area CodePhone Number
Contact Email Address:*
example@example.com
List all Standard Industrial Classification (SIC) codes for the Company's facility:
Describe the Company's business activities in detail:
Type of Business (check all that apply):

ManufacturingServiceMedicalDistribution/WarehouseOffice OnlyFabricationRetail Sales: Non-FoodRetail Sales: FoodOther
Check any and all activities occurfing at the Company's facility:

Aircraft repair/maintenanceTreating wastes from other businessesCopper or aluminum formingGrocery - retail without DeliElectrical component manufacturingGrocery - retail with DeliHospitalLeather TanningNon-ferrous metals formingOil and gas refining/extractionPainting of metalPlastics manufacturingBreweryRetail sales onlySoap or detergent manufacturingWood preservingVehicle repair shop/garagePrinting/PublisingLaundryDairy products manufacturingFertilizer manufacturingFirearms - bluingDental ServicesMedical (other than hospital)Meat, vegetable or food processing (factory level, not restaurants)Transportation equipment cleaningPowder CoatingMetal molding and castingPaint/ink manufacturingPhotographic/x-ray developingPorcelain enamelingRestaurant or fast food establishmentSmelting/metal refiningSteam power generationMetal finishing (including electroplating, electroless plating, anodizing, coloring, coating, acid rinse or acid celeaning prior to painting, chemical etching, etc.)WarehouseOther
List the square footage of the facility or facilities:*
List principal products or services if not identified above:
Estimate the total process water discharged per month:*
Number of Points of Discharge:
Restrooms:
Hand sinks:
Mop Sinks:
Floor Drains:
Other points of discharge or process discharges (please explain):
Process water disposal methods (check all that apply):

SGRWRF Sanitary SewerSeptic tank, leach fieldDirect discharge to a ditch, river, etc.No wastewater generatedHauled off-sitestorm sewerOther

Does your company or business activity use or generate any of the following?:

	Yes	No	Discharged to sanitary sewer
Antifreeze/glycol compounds
Petroleum grease/oils
Vegetable grease/oils
Acids/corrosives
Food wastes
Solvents (incl. cleaning solvents)
Flammables/Explosives
Pesticides/Herbicides
Phenols
Cyanides
Metals/metal solutions
Nitrogen containing compounds
Organic chemicals
Hazardous wastes
Radioactive isotopes
Trucked or hauled wastes
High Temperature wastes
Sulfides or hydrogen sulfide (H2S) generating wastes
High total dissolved solids (TDS)

If any chemicals identified above are discharged anywhere other than the sanitary sewer, explain:
Is your process water/wastewater treated prior to discharge?:

YesNo
If so, what treatment does it receive?:

pH adjustmentGrease separation (trap or interceptor)Sand/sedimentFilteringFlow equalizationOil/water separatorMetals treatmentOther
HAZARDOUS WASTE DISCHARGE REPORTING NOTIFICATION

This notification is intended to inform your business of their obligations under Section R317-8-8-11(14)d. of the State of Utah Water Quality Regulations. These requirements are for the reporting of discharges of hazardous waste to the sanitary sewer system.

The User shall notify the SGRWRF, the EPA Regional Waste Management Division Director, and State hazardous waste authorities in writing of any discharge into the sanitary sewer system of a substance, which, if otherwise disposed of, would be a hazardous waste unter 40 CFR Part 261.

Such 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 (continuous, batch or other). The SGRWRF is requiring this notification for a discharge of hazardous waste to the sanitary sewer system and the report shall be made immediately upon learning of the discharge.
The Authorized Representative for the Company shall sign this survey and return to:

SGRWRF Pretreatment Coordinator

3780 S. 1550 W.

St. George, Utah 84790
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 information submitted. Based on my inquiry of the person or people who manage the system, or those people 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.
Name of Authorized Representative:

First NameLast Name
Title:
Date:

MonthDayYear
Date
Signature of authorized representative:

Clear
*Please allow up to 48-hours for review during regular business days, and up to 72-hours if submitting during weekends or holidays.
SGRWRF Pretreatment Department Use Only
Is the facility in compliance with the source control program:

YesNo
Follow-Up action required:

YesNo
If follow-up required, explain:
Inspector:
Date

MonthDayYear
Date
Should be Empty: