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CITY OF WYOMING CLEAN WATER PLANT INDUSTRIAL PRETREATMENT (City of Wyoming)

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Non-Domestic User Survey
CITY OF WYOMING CLEAN WATER PLANT
INDUSTRIAL PRETREATMENT PROGRAM
NON-DOMESTIC USER SURVEY
Corporate Name Facility Name
Address - Street & Number Address - Street & Number
City Zip City Zip
Name & Title of Person Completing Survey Phone Number
Date This Company First Opened for Business (mo/yr)
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 ensure that
qualified personnel properly gather and evaluate the information submitted. Based on my
inquiry of the person or 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. [40 CFR 403.6
(a)(2)(ii)]
Signature of Responsible Official, Title Date
Print or Type Name
I.
GENERAL INFORMATION
SAVE AS PDF FOR EMAILING
PRINT FORM
Non-Domestic User Survey
II. PERSONNEL INFORMATION
1. Chief Executive Officer
Name: Title:
Mailing Address:
Phone:
2. Contact Person On-Site
Name: Title:
Mailing Address:
Phone: Email:
III. BUSINESS INFORMATION
2. In addition to municipally supplied water, do you use any other source of water
(e.g. well water)? If yes, explain type of source and approximate consumption.
3. Is your business and all its processes connected to the City of Wyoming sanitary
sewer system?
Other:
Yes
No
4. What types of waste and amounts (estimate or actual as a percentage or gallons
per day) of waste do you discharge to the sanitary sewer?
Rinse Water Cooling Water
Process Water Scrubber Water
Other (e.g., remediated groundwater)
Sanitary
Wash Water
1.
Please provide a general description of your business, industrial processes,
and end products.
Non-Domestic User Survey
5. Approximate Schedule of Operations:
Number of employees Shifts/day
Hours/Day Days/Week
Weeks/Year
6. Are operations subject to seasonal variation?
If yes, indicate seasonal dates, personnel, shifts and flow (if known):
IV. HAZARDOUS MATERIAL INFORMATION
1. Do you (or will you) use or store any acids, bases or hazardous materials that
are listed on the attached
quantity larger than 5 gallons?
and are of a
If Yes, please complete the following table (use
Yes No
additional pages if necessary):
MATERIAL VOLUME TYPE OF STORAGE LOCATION
Yes No
Priority Pollutants/Critical Materials List
Non-Domestic User Survey
2. Do you (or will you) discharge any of the above-mentioned materials to the
sanitary sewer system?
If Yes, please list pollutants and amounts (Use additional pages if necessary).
3. Is secondary containment provided for bulk chemical and storage drums and
tanks?
Yes No NA
5. Has separate storage been provided for chemicals that have hazardous
interactions, such as acid with cyanide, acids with bases?
Yes No NA
6. Does your facility have a Spill Prevention Control and Counter Measures
Program (SPCC) or a Pollution Incident Prevention Plan (PIPP)?
Yes No NA
If yes, please attach a copy of the plan.
Be sure to include your plan if replying via email!
7. Are there any floor drains located near chemicals?
Yes No
Yes No NA
4.
Is separate secondary containment provided for those processes or equipment that
contains chemicals on the Priority Pollutants/Critical Materials List?
Yes No
Non-Domestic User Survey
V. DISPOSAL PRACTICES
2. Do you have a hazardous or industrial waste hauler?
Yes No NA
If Yes, please list the name and license number:
VI. PROCESS WASTEWATERS
Yes No NA
If Yes, please indicate process and how water is used.
2.
NA
How is the process water disposed of?
Internal pretreatment system?
Yes No
Hauled offsite?
Yes No
Direct discharge to sanitary sewer?
Yes No
Other? (please list)
MATERIAL VOLUME
DISPOSAL METHOD
1.
How do you dispose of spent/used chemicals, spoilage, precipitates, or sludges?
NA
1.
Does (or will) the facility use water in any of its internal processes?
(e.g. parts washing, equipment cleaning, etc.)
Non-Domestic User Survey
Yes No NA
If Yes, please indicate type of by-product, volume, disposal method and
frequency of disposal.
5. Does the facility have any air emission control or cooling tower equipment that
discharge to the sanitary sewer?
Yes No NA
If Yes, please describe:
6. Is a grease trap, interceptor or oil/water separator located at the facility?
Yes No
If Yes, state location, capacity and cleaning frequency.
3.
If the facility has an internal pretreatment system, please describe the process
and attach a treatment diagram. Indicate whether the pretreatment system is a
batch or continuous operation, as well as discharge volumes and times. Use
additional pages if necessary.
NA
4.
Does (or will) the operation of your processes or wastewater pretreatment
facility result in by-products, residues or sludges?
Non-Domestic User Survey
VII. SAMPLING AND ANALYSIS
1. Do you have a sampling/inspection manhole in your facility’s lateral sewer
connection line?
Yes No Unknown
2. Do you sample your process or facility discharges?
If Yes, please list sampling locations, sample type (grab, time-proportional
composite, or flow-proportional composite), sample schedule and laboratory used:
VIII. STORMWATER
1. Does your facility have a Storm Water Pollution Prevention Plan (SWPPP)?
Yes No NA
2. Does your facility have a DNRE permit (e.g NPDES) for stormwater discharge?
Yes No NA
If yes, please attach a copy of the permit.
Be sure to include your plan if replying via email!
3. Are roof, parking lot, or other similar drains discharging to anything other than a
storm sewer?
If yes, please list the source, estimate area drained, and indicate where it is discharging.
Yes No NA
Yes No
Non-Domestic User Survey
IV. MODIFICATIONS
1. Describe any modifications, additions, changes or process-altering adjustments
that are anticipated to occur within the next 5 years.
X. SAFETY
1.Describe any safety precautions to be observed by those visiting your site.
Thank you for completing this survey!
We appreciate you working with us to ensure that the water we treat at the Clean
Water Plant and discharge to the Grand River is as clean and safe as possible!
Please return the completed survey and any required attachments to:
Environmental Services – Clean Water Plant
2350 Ivanrest Avenue
Wyoming, MI 49418
envsvcs@wyomingmi.gov
Priority Pollutant List
Priority Pollutants are a set of chemical pollutants we regulate, and for which we have
developed analytical test methods. The current list of 126 Priority Pollutants, shown below, can
also be found at 40 CFR Part 423, Appendix A.
These are not the only pollutants regulated in Clean Water Act programs. The list is an
important starting point for EPA to consider, for example, in developing national discharge
standards (such as Effluent Guidelines) or in national permitting programs (such as NPDES).
1. Acenaphthene
2. Acrolein
3. Acrylonitrile
4. Benzene
5. Benzidine
6. Carbon tetrachloride
7. Chlorobenzene
8. 1,2,4-trichlorobenzene
9. Hexachlorobenzene
10. 1,2-dichloroethane
11. 1,1,1-trichloreothane
12. Hexachloroethane
13. 1,1-dichloroethane
14. 1,1,2-trichloroethane
15. 1,1,2,2-tetrachloroethane
16. Chloroethane
17. (Removed)
18. Bis(2-chloroethyl) ether
19. 2-chloroethyl vinyl ethers
20. 2-chloronaphthalene
21. 2,4,6-trichlorophenol
22. Parachlorometa cresol
23. Chloroform
24. 2-chlorophenol
25. 1,2-dichlorobenzene
26. 1,3-dichlorobenzene
27. 1,4-dichlorobenzene
28. 3,3-dichlorobenzidine
29. 1,1-dichloroethylene
30. 1,2-trans-dichloroethylene
31. 2,4-dichlorophenol
32. 1,2-dichloropropane
33. 1,3-dichloropropylene
34. 2,4-dimethylphenol
35. 2,4-dinitrotoluene
36. 2,6-dinitrotoluene
37. 1,2-diphenylhydrazine
38. Ethylbenzene
39. Fluoranthene
40. 4-chlorophenyl phenyl ether
41. 4-bromophenyl phenyl ether
42. Bis(2-chloroisopropyl) ether
43. Bis(2-chloroethoxy) methane
44. Methylene chloride
45. Methyl chloride
46. Methyl bromide
47. Bromoform
48. Dichlorobromomethane
49. (Removed)
50. (Removed)
51. Chlorodibromomethane
52. Hexachlorobutadiene
53. Hexachlorocyclopentadiene
54. Isophorone
55. Naphthalene
56. Nitrobenzene
57. 2-nitrophenol
58. 4-nitrophenol
59. 2,4-dinitrophenol
60. 4,6-dinitro-o-cresol
61. N-nitrosodimethylamine
62. N-nitrosodiphenylamine
63. N-nitrosodi-n-propylamine
64. Pentachlorophenol
65. Phenol
66. Bis(2-ethylhexyl) phthalate
67. Butyl benzyl phthalate
68. Di-N-Butyl Phthalate
2
69. Di-n-octyl phthalate
70. Diethyl Phthalate
71. Dimethyl phthalate
72. Benzo(a) anthracene
73. Benzo(a) pyrene
74. Benzo(b) fluoranthene
75. Benzo(k) fluoranthene
76. Chrysene
77. Acenaphthylene
78. Anthracene
79. Benzo(ghi) perylene
80. Fluorene
81. Phenanthrene
82. Dibenzo(,h) anthracene
83. Indeno (1,2,3-cd) pyrene
84. Pyrene
85. Tetrachloroethylene
86. Toluene
87. Trichloroethylene
88. Vinyl chloride
89. Aldrin
90. Dieldrin
91. Chlordane
92. 4,4-DDT
93. 4,4-DDE
94. 4,4-DDD
95. Alpha-endosulfan
96. Beta-endosulfan
97. Endosulfan sulfate
98. Endrin
99. Endrin aldehyde
100. Heptachlor
101. Heptachlor epoxide
102. Alpha-BHC
103. Beta-BHC
104. Gamma-BHC
105. Delta-BHC
106. PCB-1242 (Arochlor 1242)
107. PCB-1254 (Arochlor 1254)
108. PCB-1221 (Arochlor 1221)
109. PCB-1232 (Arochlor 1232)
110. PCB-1248 (Arochlor 1248)
111. PCB-1260 (Arochlor 1260)
112. PCB-1016 (Arochlor 1016)
113. Toxaphene
114. Antimony
115. Arsenic
116. Asbestos
117. Beryllium
118. Cadmium
119. Chromium
120. Copper
121. Cyanide, Total
122. Lead
123. Mercury
124. Nickel
125. Selenium
126. Silver
127. Thallium
128. Zinc
129. 2,3,7,8-TCDD
Additional Information
Toxic and Priority Pollutants Under the Clean Water Act
December 2014
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Completed 5 August 2020

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