PO Box 4398, Odessa, Texas 79760
I. General Information
A. Date________________________
B. Type of Application _____New _____Renewed
C. Facility Site Information
Business Name__________________________________________________________
Physical Address_________________________________________________________
Mailing Address ______________________________________ Zip Code ___________
Business Telephone: ______________________________
D. Signatory Official (See Attachment A for signatory requirements)
Signatory’s Name _______________________________________________________
Title_____________________________ Business Telephone ___________________
Business Address _____________________________________ Zip Code __________
E. Local Contact (if different from Signatory Official)
Contact Name _________________________________________________________
Title _____________________________ Business Telephone ___________________
Business Address _____________________________________ Zip Code _________
II. Description of Activities
A. Type (Please check all that apply)
_____Food Service
_____Equipment Service/Repair
_____Laundry/Dry Cleaner
_____Machine Shop
_____Gas/Automotive Service
_____Car Wash
_____Office Building
_____Photo Processing
Other _________________________________________________________________
PO Box 4398, Odessa, Texas 79760
B. Standard Industrial Classification Code(s) (SIC). Please list all that apply. This code can be
found on your Employers’ Quarterly Report.
________________ ________________ _________________ ________________
Manufacturing Information
Are you a manufacturer? _____Yes - Complete Attachment B
_____No - Continue to Section III
III. Facility Data
A. Property Information
Utility Account Location #____________________ Customer #____________________
Name on Utilities Account __________________________________________________
Address on Utilities Account ________________________________________________
Do you own or lease the property? ___________________________________________
If leasing, name of property owner ___________________________________________
B. Days of Operation (Circle) Sun Mon Tues Wed Thurs Fri Sat
C. Hours of Operation (Note Variations)
_________ to _________ Sun Mon Tues Wed Thurs Fri Sat
_________ to _________ Sun Mon Tues Wed Thurs Fri Sat
D. Is your facility located outside the City limits? _______Yes ______No
E. Number of employees and/or people on site ___________________________________
IV. Water Usage
A. Source of Water (Please check all that apply)
_____City of Odessa Other_________________________________
_____ Water Well Number of Wells _______________________
B. Total Water Consumption (gallons per day/gpd)
1. Volume of City water used per day ___________________________________
Calculate as follows: gallons on utility bill X 1000 divided by days of use
PO Box 4398, Odessa, Texas 79760
2. Water well or other:
a. Flow meter _____________gpd
b. Estimation _____________gpd
c. Basis of Estimation __________________________________
3. Total combined daily water consumption ________________gpd
4. Estimated water usage if not yet open ________________gpd
C. Water/Wastewater Generation Processes (E=Estimated; M=Measured)
Water Consumption Gallons Per Day Estimated/Measured
Contact Cooling
Non-contact Cooling
Boiler Feed
Air Pollution equipment
Contained in Product
Plant/Equipment Washdown
Lawn Irrigation
Total Water Usage GPD (Should match total from Section IV.B.)
PO Box 4398, Odessa, Texas 79760
Wastewater Flows
Per Day
to Sewer System
Cool Tower Blowdown
Cooling Water
Boiler Blowdown
Air Pollution Equipment
Plant/Equipment Washdown
Backwash (Filters)
Total Discharge to sewer system GPD
V. Wastewater Discharge Information
A. Location of Discharge (check all that apply)
1. ___ Odessa Wastewater Collection System
2. Other
a. ___Surface Discharge
b. ___Sump/Holding Tank ______ ______________________
c. ___Septic Tank
**If not connected to City Wastewater Collection system, go to Section VII.
B. Time of Discharge
1. Maximum flows ___________ to __________
2. Minimum flows ___________ to __________
PO Box 4398, Odessa, Texas 79760
3. Flow type (check one)
a. _______Continuous
b. _______Intermittent
c. _______Batch
C. Plumbing connections to the wastewater collection system. List all types (e.g. floor drains,
sinks, restrooms, etc). Please provide blueprint or map, if possible.
___________________________ _________________________________________
___________________________ _________________________________________
___________________________ _________________________________________
___________________________ _________________________________________
___________________________ _________________________________________
___________________________ _________________________________________
___________________________ _________________________________________
___________________________ _________________________________________
D. List the size and location of all discharge sewer lines which connect to the City wastewater
collection system. (Provide map if possible).
________________________ _______________________________________________
________________________ _______________________________________________
E. Is a sampling portal located on the sewer line? (Minimum of a 4" 2-way cleanout).
__________Yes ___________No
Describe location ___________________________________________________________
F. Does storm water or roof runoff discharge to the wastewater collection system through any
__________Yes __________No
PO Box 4398, Odessa, Texas 79760
VI. Pretreatment Information (Please note all that apply)
Size Location
Food grease trap (pot type) _________ ________________________________
Food grease trap (submerged) _________ ________________________________
Enzyme injection _________ ________________________________
Sand/lint trap _________ ________________________________
Acid trap _________ ________________________________
Silver reclaimer _________ ________________________________
pH control _________ ________________________________
Other (describe) ___________________ _________ ________________________________
None ____________
VII. Facility Site Information
A. Solid Wastes Generated
Lbs or Gals Location
Cleaning solutions
Caustic/jet vat ________ _______________________________________
Solvent vat ________ _______________________________________
Acid vat ________ _______________________________________
Other __________________ ________ _______________________________________
Waste oil
Waste Oil Filters ________ _______________________________________
Machine coolants ________ _______________________________________
Paint wastes/filters ________ _______________________________________
Waste antifreeze ________ _______________________________________
Asbestos/PCB/Radioactive ________ _______________________________________
Waste grease (fryolator) ________ _______________________________________
PO Box 4398, Odessa, Texas 79760
Type Lbs or Gals Location
Other_______________________ ________ _______________________________________
B. Bulk Material Storage (above or below ground)
Size Location
Fuel tank ________ ______________________________________
Non-hazardous material ________ ______________________________________
Hazardous material (non-fuel) ________ ______________________________________
Hazardous waste ________ ______________________________________
Waste oil ________ ______________________________________
Chemical blending tanks ________ ______________________________________
Other ____________________ ________ ______________________________________
None ____________________
C. Please provide a Material Safety Data Sheet (MSDS) for each chemical stored in bulk onsite
in quantities greater than 5 gallons and chemicals discharged to the wastewater collection
D. Spill Control Plan
1. Has this facility developed a Spill Control Plan to prevent the discharge of
chemicals onsite to the wastewater collection system?
_________Yes _________No
If yes, please attach a copy of the Plan.
PO Box 4398, Odessa, Texas 79760
VIII. Disposal Methods
A. Please provide documentation (e.g. manifests, waste receipts, etc) concerning offsite
disposal of all wastes other than trash.
Waste Type Transporter Location
B. Has any of the wastes generated at this site been previously analyzed or classified as a
hazardous waste?
__________Yes ___________No __________N/A
If yes, please provide a copy of the classification and/or analytical results.
NOTE: If you are discharging or requesting discharge of a hazardous waste as defined by 40
CFR Part 261 to the wastewater collection system, you must notify the City of Odessa
Pretreatment Division, the EPA Regional Waste Management Division Director, and the
TCEQ Hazardous Waste Authority. This 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 (e.g. continuous, batch, etc). If you discharge more than 100 kilograms of the
waste during a calendar month, you must contact the Pretreatment Division for additional
reporting requirements and restrictions.
C. Does this facility have
Yes (Provide Number)
1. Texas Solid Waste Number __________________ ____
2. US EPA Registration Number __________________ ____
If applicable, provide a copy of the Texas or EPA correspondence issuing the number.
PO Box 4398, Odessa, Texas 79760
IX. Pollution Prevention Activities
Please list all pollution prevention activities you have incorporated or plan to incorporate into your
business operations in the next three (3) years.
X.Compliance with Ordinance Requirements
To the best of my knowledge, the discharges from this facility will meet the requirements of the Sewage
Quality Control Ordinance, No. 93-75 as amended. _____Yes _____No
If no, please list the pretreatment facilities and size of pretreatment facilities proposed for installation to
ensure compliance. (Please note all facilities must be approved by the Building Inspection and
Pretreatment Divisions.
Authorized Representative Statement:
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 and
evaluated 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 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/or imprisonment for knowing violations.
Print Name _________________________________________
Title _________________________________________
Signature _________________________________________
Phone _________________________________________
Date _________________________________________
Important Notice:
The information provided in this Application, other information submitted by your company, and information
gathered by the City in conjunction with the operations and discharges from your company are subject to Open
Records Requests. If any of the information submitted by your company is designated as confidential as defined
by Section 552.110 of the Texas Public Information Act, you must assert it as such at the time of submission.
Each page containing confidential information must be marked “Confidential Business Information”. This
information, if it is determined that it meets the criteria of the Texas Public Information Act, will be handled in
accordance with the procedures described in the Act. If no claim of confidentiality is made at the time of
submission, the information will be made available to the public without further notice.
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PO Box 4398, Odessa, Texas 79760
An authorized representative shall be:
I. If the user is a corporation:
A. 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.
B. The manager of one or more manufacturing, production, or operation facilities employing more
than two hundred fifty (250) persons or having gross annual sales or expenditures exceeding
twenty-five (25) million dollars (in second quarter 1980 dollars), if authority to sign documents has
been assigned or delegated to the manager in accordance with corporate procedures.
II. If the user is a partnership or sole proprietorship:
The general partner or proprietor, respectively.
III. If the user is a federal, state, or local governmental facility:
A director or highest official appointed, designated, or elected to oversee the operation and performance
of the activities of the government facility, or their designee.
IV. The individuals described in the above paragraphs may designate another authorized representative if
the authorization is in writing, the authorization specifies the individual or position responsible for the
overall operation 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 Director of
PO Box 4398, Odessa, Texas 79760
Do you participate in any of the following manufacturing processes?
Aluminum Forming _____ _____
Asbestos Manufacturing _____ _____
Battery Manufacturing _____ _____
Canned and Preserved Fruits and Vegetables _____ _____
Canned and Preserved Seafood _____ _____
Carbon Black _____ _____
Cement Manufacturing _____ _____
Centralized Waste Treatment _____ _____
Coal Mining _____ _____
Coil Coating _____ _____
Copper Forming _____ _____
Dairy Products _____ _____
Electric and Electronic Components _____ _____
Electroplating _____ _____
Feedlots _____ _____
Ferroalloy _____ _____
Fertilizers _____ _____
Glass Manufacturing _____ _____
Grain Mills _____ _____
Gum and Wood Chemicals _____ _____
Hospital _____ _____
Ink Formulating _____ _____
Inorganic Chemicals _____ _____
Iron and Steel _____ _____
Landfills _____ _____
Leather Tanning and Finishing _____ _____
Meat Processing _____ _____
Metal Finishing _____ _____
Metal Molding and Casting _____ _____
Mineral Mining and Processing _____ _____
Nonferrous Metals Forming and Metal Powder _____ _____
Nonferrous Metals _____ _____
Oil and Gas Extraction _____ _____
Ore Mining and Dressing _____ _____
Organic Chemical, Plastics, and Synthetic Fibers _____ _____
Paint Formulating _____ _____
Paving and Roofing Material _____ _____
Pesticide Chemicals _____ _____
Petroleum Refining _____ _____
Pharmaceutical _____ _____
Phosphate _____ _____
Photographic _____ _____
Plastics Molding and Forming _____ _____
Porcelain and Enameling _____ _____
PO Box 4398, Odessa, Texas 79760
Pulp, Paper, and Paperboard _____ _____
Rubber Manufacturing _____ _____
Soap and Detergent _____ _____
Steam Electric Power Generation _____ _____
Sugar Processing _____ _____
Textile Mills _____ _____
Timber Products Processing _____ _____
Transportation Equipment Cleaning _____ _____
Waste Combustors _____ _____