Fillable Form 1: (City of West Memphis)

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Form 1: (City of West Memphis)

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Country of origin: US
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U.S.A. forms for City of West Memphis

BROWSE CITY OF WEST MEMPHIS (AR) FORMS

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1
Address:
Fax Number:
Web Site Address:
2
Corporate Headquarters/Registered Agent:
Address:
3
Standard Industrial Classification (SIC) Number:
4
List other environmental permits held at this time:
North American Industrial Classification (NAIC) Number:
City, State, Zip:
Mailing Address:
Telephone Number:
City, State, Zip:
Firm Name:
Telephone Number:
Email Address:
Telephone Number:
Contact Name:
Contact Person:
Application for Permit
For Discharge of Industrial Waste
To City of West Memphis
5
Discharge to West Memphis Sewer
Process Wastewater from
Operation
Process Wastewater from
Operation
Domestic Wastewater (Sanitary)
Noncontact Cooling Water
Total Process and Sanitary
List any periodic or seasonal variations:
6
Units Sewer Use
Ordinance
BOD5 mg/L
250
TSS mg/L
250
pH S.U. 5.5-10.0
mg/L 100
C
o
40
o
Parameter
Concentration
Temperature
Oil and Grease
Average Daily
Maximum Daily
Average Daily
(30) day
Maximum Daily
(1) day
Projected for the next three (3) years. (In Gallons)
Quantity of Wastewater: (Estimate if new Facility):
7
30 Day Average
Concentration
Priority Pollutant (Name)
Priority Pollutants: List any Priority Pollutants (Attachment 1) that are known to
be present in the wastewater of processes found at your facility in the spaces
provided below. Industries discharging any of the pollutants listed in
Attachment No.1 must perform sampling and analysis necessary to develop
information required to complete this section.
1 Day Maximum
30 Day Average
1 Day Maximum
30 Day Average
1 Day Maximum
1 Day Maximum
30 Day Average
30 Day Average
1 Day Average
(Attach additional sheets as needed)
1 Day Maximum
30 Day Average
1 Day Average
30 Day Average
1 Day Average
30 Day Average
1 Day Maximum
30 Day Average
1 Day Maximum
30 Day Average
1 Day Maximum
30 Day Average
1 Day Maximum
30 Day Average
8
9
10
Describe the nature of manufacturing/commercial activities of the plant.
Describe in detail any water usage other than sanitary or noncontact cooling
water. (Attach additional sheets if needed.)
Amount used per day
List all chemical/products with MSDS information at your facility that may come
into contact with water at any time. Include any chemicals that are stored in an
area adjacent to a wastestream that could become contaminated if spilled.
(Attach additional sheets if needed.)
Amount stored at facility
General plant processes and wastewater lines (including the location of all floor
drains). Include any existing and proposed pretreatment systems, the location
and size of all existing and proposed connections to the West Memphis Utility
Collection System. Also, include details of proposed monitoring access facilities.
Chemical Name
Attach sketches of the following to this document:
11 Describe any product(s) manufactured or assembled at the plant by type and
amount.
12
13
14
YES NO
Describe the type and amount of raw material used at the facility:
If you answered Yes to the above question, to which of the National Categorical
Pretreatment Standards are you subject?
What are the hours of operation at your facility:
What are the actual/proposed hours of operation of any pretreatment system at
your facility:
Is your manufacturing/commercial operation subject to the National
Categorical Pretreatment Standards?
15
YES NO
Explain:
16
17
shall submit a progress report to the Director of Environmental Quality
indicating the following:
limitations? Explain:
limitations, submit the compliance schedule by which your facility will attain final
compliance with the applicable limitations.
The expected dates of completion of such events shall also be given.
The completion dates of any two successive events shall not exceed nine months.
Within fourteen (14) days after the completion of each event, the Industrial User
maintenance (O&M) are required to meet National Categorical discharge
West Memphis Sewer Use Ordinance wastewater discharge limitations are not
being met on a consistent basis, is additional pretreatment and/or alteration of
If the applicable National Categorical Pretreatment Standards and the City of
The Compliance Schedule shall contain a list of major events leading to compliance.
If additional Pretreatment and/or an alteration of current operation and
current operations and maintenance (O&M) required by your firm to meet
The following questions (15-18) deal with current West Memphis
Industrial Pretreatment Permit holder.
Are the applicable National Categorical Pretreatment Standards and the City
of West Memphis Sewer Use Ordinance wastewater discharge limitations
being met on a consistent basis?
17
Comment:
18
19
The permit application must be certified by an authorized representative of the
Industrial User. Failure to certify will result in denial of the permit.
“I, the undersigned applicant, being the authorized representative of the herein named
company, do hereby request a permit to use or to continue to use an industrial sewer
connection at the location indicated herein and do agree to comply with applicable
Describe any Best Management Practices (BMP) activities which are either
Describe any Pollution Prevention Project activities which are either planned or
have been implemented:
planned or have been implemented:
Da+BQ1+BR1:BZ25+BQ1:BZ27+BQ1+BR1:B+BR1:BZ25+BR1:BZ25
If the event is not completed as scheduled, the reason for the delay.
return to the established schedule.
The expected date of completion and steps taken by the Industrial User to
Title:
Date:
Before me, the undersigned authority, on this day personally appeared
of
a corporation known to me to be the person whose name is subscribed to the forgoing
instrument, and acknowledged to me that he/she executed the same for purposes and
considerations therein expressed, in the capacity therein stated as the act and deed
of said corporation.
day of 2017
County State
Certified by (Authorized Representative)
Given under my hand and seal of office on this
Notary Public in and for
State of
County of
Name and Telephone Number of person to contact regarding permit information:
Corporate Acknowledgment
Name of Signee: (Please Print)
under my direction or supervision in accordance with a system designed to assure that
I certify under penalty of law that this document and all attachments were prepared
provisions of West Memphis City Code regulating the use of public sewage works.
and imprisonment for knowing violations”
significant penalties for submitting false information, including the possibility of fines
my knowledge and belief, true, accurate and complete. I am aware that there are
responsible for gathering the information, the information submitted is, to the best of
my inquiry of the person or persons who manage the system, or those persons directly
qualified personnel properly gather and evaluate the information submitted. Based on
VOLATILE COMPOUNDS
02 ACROLEIN 088 VINYL CHLORIDE
004 BENZENE 003 ACRYLONITRILE
006 CARBON TETRACHLORIDE 047 BROMOFORM
051 CHLORODIBROMOMETHANE 007 CHLOROBENZENE
019 2-CHLOROETHYLVINLY ETHER 016 CHLOROETHANE
048 DICHLOROBROMOMETHANE 023 CHLOROFORM
010 1,2-DICHLOROETHANE 013 1,1-DICHLOROETHANE
032 1,2-DICHLOROPROPANE 029
1,1-DICHLOROETHYLENE
038 ETHYLBENZENE 033 1,3-DICHLOROPROPYLENE
045 METHYL CHLORIDE 046 METHYL BROMIDE
015 1,1,2,2-TETRACHLOROETHANE 044 METHYLENE CHLORIDE
086 TOLUENE 085 TETRACHLOROETHYLENE
011 1,1,1-TRICHLOROETHANE 030 1,2-TRANS-DICHLOROETHYLENE
087 TRICHLOROETHYLENE 014 1,1,2-TRICHLOROETHANE
ACID COMPOUNDS
024 CHLOROPHENOL 031 2,4-DICHLOROPHENOL
034 2,4-DIMETHYLPHENOL 060 4,6-DINITRO-O-CRESOL
059 2,4-DINITROPHENOL 057 2-NITROPHENOL
058 4-NITROPHENOL 022 P-CHLOTO-M-CRESOL
064 PENTACHLOROPHENOL 065 PHENOL
021 2,4,6-TRICHLOROPHENOL
PRIORITY POLLUTANTS
BASE/NEUTRAL COMPOUNDS
001 ACENAPHTHENE 077 ACENAPHTYLENE
078 ANTHRACENE 005 BENZIDINE
072 BENZO(A)ANTHRACENE 073 BENZO(A)PYRENE
074 BENZO(B)FLUORANTHENE 079 BENZO(GHI)PERYLENE
075 BENZO(K)FLUORANTHENE 043 BIS(2-CHLOROETHOXY)METHANE
018 BIS(2-CHLOROETHYL)ETHER 042 BIS(2-CHLOROISOPROPYL)ETHER
017 BIS(CHLOROMETHYL)ETHER 041 4-BROMOPHENYL PHENYL ETHER
066 BIS(2-ETHYLHEZYL)PHTHALATE 020 2-CHLORONAPHTHALENE
067 BUTYL BENZYL PHTHALATE 076 CHRYSENE
025 1,2-DICHLOROBENZENE 040 4-CHLOROPHENYL PHENYL ETHER
082 DIBENZO(A,H)ANTHRACENE 027 1,4-DICHLOROBENZENE
026 1,3-DICHLOROBENZENE 070 DIETHYL PHTHALATE
028 3,3-DICHLOROBENZIDINE 068 DI-N-BUTYL PHTHALATE
071 DIMETHYL PHTHALATE 036 2,6-DINITROTOLUENE
035 2,4-DINITHROTOLUENE 081 PHENANTHRENE
069 DI-N-OCTYL PHTHALATE 009 HEXACHLOROBENZENE
039 FLUORANTHENE 053 HEXACHLOROCYCLOPENTADIEN
080 FLUORENE 083 INDENO(1,2,3-CD)PYRENE
052 HEZACHLOROBUTADIENE 055 NAPHTHALENE
012 HEXACHLOROETHANE 061 N-NITROSODIMETHYLAMINE
054 ISOPHORONE 062 N-NITROSODIPHENYLAMINE
056 NITROBENZENE 084 PYRENE
008 1,2,4-TRICHLOROBENZENE 063 N-NITROSODI-N-PROPYLAMINE
037 1,2-DIPHENYLHYDRAZINE (AS AZOBENZENE)
PESTICIDES AND PCB'S
089 ALDRINE 104 GAMMA-BHC
102 ALPHA-BHC 105 DELTA-BHC
103 BETA-BHC 091 CHLORDANE
092 4,4'DDT 093 4,4'DDE
094 4,4'DDD 090 DIELDRIN
095 ALPHA-ENDOSULFAN 096 DETA-ENDOSULFAN
097 ENDOSULFAN SULFATE 098 ENDRIN
099 ENDRIN ALDEHYDE 113 TOXAPHENE
106 PCB-1242 109 PCB-1232
107 PCB-1254 111 PCB-1260
100 HEPTACHLOR 101 HEPTACHLOR EPOXIDE
METALS AND CYANIDE
114 ANTIMONY 115 ARSENIC
117 BERYLLIUM 118 CADMIUM
119 CHROMIUM 120 COPPER
122 LEAD 123 MERCURY
124 NICKEL 125 SELENIUM
126 SILVER 127 THALLIUM
128 ZINC 121 CYANIDE
MISCELLANEOUS
129 2,3,7,8-TETRACHLORODIBENZO-P-DIOXIN (TCDD)
116 ASBESTOS
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Form 1: (City of West Memphis)

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Completed 17 July 2020

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