General Industrial Wastewater Discharge Permit

General Industrial Wastewater Discharge Permit
Application for Non-Significant Industrial User
General Industrial Wastewater Discharge Permit
Permit Number: CWL001
Application Type*

NewRenewalTransfer

Facility Information
Firm Name*
Facility Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is Physical Address same as Mailing Address

Yes
Facility Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Document Review Certification Statement*

I have read and reviewed the following documents: 1 - CWL Application Process/Procedure for New & Structural Modifications; 2 - CWL Interceptor Requirements & Installation Guidelines.
Sand/Oil Interceptor Design

Contact Information
Contact Person 1*

First NameLast Name
Contact Person 1 - Phone Number*

Area CodePhone Number
Contact Person 1 - Email*
example@example.com
Contact Person 2

First NameLast Name
Contact Person 2 - Phone Number

Area CodePhone Number
Contact Person 2 - Email
example@example.com

An Authorized Representative may be:

(A) If the Industrial User is a corporation, the Authorized Representative shall be as follows:

(i) The president, secretary, treasurer, or a vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision-making functions for the corporation.

(ii) The manager of one or more manufacturing, production, or operation facilities, provided the manager is authorized to make management decisions which govern the operation of the regulated facility, including having explicit or implicit duty of making major capital investment recommendations, and initiate and direct other comprehensive measures to assure long-term environmental compliance with environmental laws and regulations; can ensure that the necessary systems are established or actions taken to gather complete and accurate information for individual wastewater discharge permit requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures.

(B) If the Industrial User is a partnership or sole proprietorship, an Authorized Representative shall be a general partner or proprietor, respectively.

(C) If the Industrial User is a Federal, State, or local government facility, an Authorized Representative shall be a director or highest official appointed or designated to oversee the operations and performance of the activities of the government facility, or the Authorized Representative's designee.

(D) The Authorized Representative described
above may designate a Duly Authorized Representative if the authorization is in writing, the authorization specifies the individual or position responsible for the overall operations of the facility from which the discharge originates or having overall responsibility for environmental matters for the company and the written authorization is submitted to the Manager of CWL.
I understand who qualifies as an Authorized Representative
Water Meter Certification Statement

"I understand that by not installing a seperate water meter specifically to measure water flows to the wash only, any applicable CWL Laboratory charges will be based on 100 percent of the water meter reading."
Certified By (authorized representative)*

First NameLast Name
Title*
Signature*

Clear
Date*

MonthDayYear
Date
Permit Transfer Certification Statement

"I certify under penalty of law that I, as new owner/operator, have no immediate intent to change the facility's operations and process and acknowledge full responsibility for complying with the existing wastewater discharge permit effective on the transfer date of ownership."
The ownership date of transfer*

MonthDayYear
Date
Certified By (authorized representative)*

First NameLast Name
Title*
Signature*

Clear
Date*

MonthDayYear
Date
Permit Application Certification Statement

"I declare that I have examined this report and to the best of my knowledge and belief that it is true, correct and complete."
Certified By (authorized representative)*

First NameLast Name
Title*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

General Industrial Wastewater Discharge Permit

Facility Information

Contact Information

Water Meter Certification Statement

Permit Transfer Certification Statement

Permit Application Certification Statement