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City of Bethlehem
Wastewater Treatment Plant
Municipal Industrial Pretreatment Program
Industrial Wastewater Discharge Permit Application
Section A General Information
1. Company name, mailing address, telephone number, fax number, and municipality.
Telephone Number
Fax Number
Municipality
2. Address of production or manufacturing facility. If same as above, check here
Municipality
3. Person authorized to represent this facility in official dealings with the City of Bethlehem, designated
to receive and send all reports, communications, etc., and who will be the Authorized
Representative as described in Article 923 on page 9 of this application.
Name
Title
Address
Telephone Number
Fax Number
Email Address
4. Is this a proposed or existing facility? Proposed Existing
5. List Standard Industrial Classification (SIC) Codes and North American Industry Classification
System (NAICS) Codes for each process at this facility
Process
SIC Code
NAICS Code
6. Identify and briefly describe each process that produces waste. Include the year in which discharge
of each process began. Attach additional sheets if necessary.
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7. If this facility employs processes in any of the industrial categories listed below, place a check
beside the category. Check all that apply.
Airport Deicing
Leather Tanning and Finishing
Aluminum Forming
Meat and Poultry Products
Asbestos Manufacturing
Metal Finishing
Battery Manufacturing
Metal Products and Machinery
Canned and Preserved Fruits and Vegetables Processing
Metals Molding and Casting
Canned and Preserved Seafood Processing
Mineral Mining and Processing
Carbon Black Manufacturing
Nonferrous Metals Forming and Metal Powders
Cement Manufacturing
Nonferrous Metals Manufacturing
Centralized Waste Treatment
Oil and Gas Extraction
Coal Mining
Ore Mining and Dressing
Coil Coating
Organic Chemicals, Plastics, and Synthetic Fibers
Concentrated Animal Feeding Operations
Paint Formulating
Concentrated Aquatic Animal Production
Paving and Roofing Materials
Construction and Development
Pesticide Chemicals
Copper Forming
Petroleum Refining
Dairy Products Processing
Pharmaceutical Manufacturing
Electrical and Electric Components
Phosphate Manufacturing
Electroplating
Photographic
Explosives Manufacturing
Plastics Molding and Forming
Ferroalloy Manufacturing
Porcelain Enameling
Fertilizer Manufacturing
Pulp, Paper, and Paperboard
Glass Manufacturing
Rubber Manufacturing
Grain Mills
Soap and Detergent Manufacturing
Gum and Wood Chemicals Manufacturing
Steam Electric Power Generating
Hospitals
Sugar Processing
Ink Formulating
Textile Mills
Inorganic Chemicals Manufacturing
Timber Products Processing
Iron and Steel Manufacturing
Transportation Equipment Cleaning
Landfills
Waste Combustors
8. This facility generates the following types of wastewaters. Check all that apply.
domestic (bathrooms, showers, etc.)
process
facility/equipment cleaning
cooling water, noncontact
cooling water, contact
boiler/tower blowdown
air pollution unit
other (describe)
9. List the permit number for any environmental permits held by this facility.
NPDES General
NPDES Stormwater
NPDES Industrial
Hazardous Waste
Air
Solid Waste Disposal
Health/Medical
Other (specify)
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10. Provide employee shift information.
Facility hours of operation:
Starting times of each shift:
1
st
2
nd
3
rd
Number of employees per shift: 1
st
2
nd
3
rd
11. List all environmental emergency response plans (Spill Prevention Control and Countermeasures
(SPCC) Plan, Preparedness, Prevention and Contingency (PPC) Plan, Spill Prevention Response
(SPR) Plan, etc.) prepared for the facility and the date of the latest revisions.
In accordance with City of Bethlehem Ordinance Article 923 Section 923.02(h), if determined to be
necessary, a Spill Prevention Plan shall be supplied to the City. A Spill Prevention Plan shall contain,
at a minimum, the following elements:
Description of discharge practices, including non-routine batch discharges;
Description of stored chemicals;
Procedure for immediately notifying the POTW of slug load/accidental discharges, including any
discharges which would violate a prohibition under 40 CFR 403.5(b), with procedures for follow-
up written notification within five days;
If necessary, procedure to prevent adverse impact from accidental spills, including inspection and
maintenance of storage areas, handling and transfer of materials, loading and unloading
operations, control of plant site run-off, worker training, building of containment structures or
equipment, measures for containing toxic organic pollutants (including solvents), and/or
measures and equipment necessary for emergency responses.
12. Is this facility planning any process changes or expansions over the next three years? Yes No
If yes, discuss the anticipated changes in process and/or sanitary wastewater quantity or quality.
13. If applicable, describe any environmental improvement projects anticipated for implementation at the
facility in the next three years.
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Section B Facility Operation Characteristics
Complete the following for each activity or process at this facility that produces wastewater. Attach
additional copies as needed.
1. Process or product manufactured:
2. On a separate sheet, provide a flow chart of the process. Identify all manufacturing steps, water
supply points, wastewater discharge points, wastewater sampling points, recycling routes, and
pretreatment facilities.
3. Production process is:
Continuous
Batch Average number of batches per 24-hour day
Both %Batch %Continuous
4. On a separate sheet, list all raw materials, process additives, and any cleaning products used in
this process. Attach safety data sheets (SDSs) and/or labels showing product components.
5. Is this process subject to seasonal variation? Yes No
If yes, briefly describe seasonal production cycle:
6. Does pretreatment occur on the wastewater of this process before discharge to the sanitary sewer?
Yes
No If yes, briefly describe the pretreatment process:
7. Does this process waste stream combine with any other process waste streams or with domestic
waste prior to pretreatment or entering the sanitary sewer? Yes No
If yes, describe which waste streams combine and where:
8. This process generates the following types of wastes. Check all that apply and list amounts
(gallons or pounds per month or year).
acid, alkaline or corrosive materials
flammable or explosive materials
heavy metal sludges
inks or dyes
metal solutions
oil/grease
paints
pesticides
plating wastes
phenols and/or other toxic organic compounds
pretreatment sludges
radioactive materials
soaps or detergents in large amounts
other (describe)
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Section C – Water Supply and Usage
1. What are the facility’s sources of water? Check all that apply and list the average gallons of water
used per day.
municipal supply
private well(s)
surface water intake
trucked/hauled
other (describe)
2. List the location, size, associated account number, usage in gallons per day, and process supplied
for all water meters in the facility.
Location
Size
Account No.
Usage (gpd)
Process Supplied
3. Describe any raw water treatment processes in use.
4. What are the uses of water at the facility? Check all that apply. List the average gallons of water
used per day for each use.
domestic wastes (bathrooms)
cafeteria/food prep
cooling water, contact
cooling water, noncontact
boiler/tower blowdown
process water
water included in product
equipment/facility cleaning
air pollution control
other (describe)
other (describe)
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Section D Wastewater Characteristics
1. How does wastewater discharge from the facility? Check all that apply. List the average gallons of
wastewater per day for each discharge.
sanitary sewer
storm sewer
recycled
permitted discharge point NPDES permit #
evaporation
hauled off site*
other (describe)
* Provide name, address, and telephone number of any waste haulers.
2. List all facility connections to sanitary sewer mains. Attach a map or diagram for reference.
Location
Size
Wastewater Source(s)
Gallons per Day
3. Fully describe all available sampling points for this facility’s wastewater discharge locations
identified in D.2. above.
4. Are wastewater discharges to sanitary sewer intermittent or steady? If intermittent, describe
schedule as fully as possible, including peak rates, times, and duration of discharges.
5. Provide the following information for all wastewater flow meters at this facility.
Location
Size
Type
Gallons per Day
Measures Flow From
6. Describe any wastewater treatment or pretreatment equipment in use.
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7. Describe any Federal Categorical Pretreatment Standards that apply to the facility. If production
based discharge limits apply, include relevant production records with this application.
a. Does the facility meet applicable Federal Categorical Pretreatment Standards on a consistent
basis? Yes No N/A
b. Are additional pretreatment facilities and/or operation and maintenance procedures required to
meet Federal Categorical Pretreatment Standards? If so, describe and list the schedule by
which they will be provided.
Section E Solid Wastes
If the facility does not generate solid wastes other than business waste, skip to section F.
1. What types of solid waste does this facility generate? Check all that apply.
municipal waste
residual waste
hazardous waste
infectious waste
chemotherapeutic waste
other (describe)
other (describe)
2. Describe solid waste disposal methods for the facility. Include name, address, and phone number
of any haulers, and disposal amounts per month or year.
3. Does the facility generate pretreatment residuals? Yes No If yes, identify the following
characteristics of these pretreatment residuals.
Quantity:
gallons per day or
pounds per day (dry weight)
Moisture Content:
percent solids
Disposal Method
4. Does the facility generate any other types of solid waste? Yes No If yes, identify the following
characteristics of the waste.
Description
Quantity:
gallons per day or
pounds per day (dry weight)
Moisture Content:
percent solids
Disposal Method
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Section F Wastewater Monitoring
1. Are any of the priority pollutants in Table I listed at the end of the application used at this facility in
manufacturing the product or generated as a byproduct? If so, please note on Table I.
2. List any other pollutants known or anticipated to be present in the facility or in the wastewater
discharged to the sanitary sewer.
3. Provide laboratory analysis results for each of the following parameters. Perform sampling and
laboratory analyses in accordance with EPA regulations listed in 40 CFR Part 136. Samples must
be representative of the facility’s typical wastewater discharge. Be sure to describe the sample
collection location and attach the original laboratory report. Attach additional sheets for more than
one sample location. Results from samples taken within the last six months may be used. For a
proposed facility not yet discharging, results from a similar facility located elsewhere may be used.
Sample collection location:
Category One
Result
Unit
Ammonia (NH
3
-N)
Biological oxygen demand (BOD
5
)
Chemical oxygen demand (COD)
Color
Oil and grease
pH
Temperature
Total suspended solids (TSS)
Total petroleum hydrocarbons (TPH)
Category Two
Result
Unit
Arsenic, total
Cadmium, total
Chromium, total
Copper, total
Lead, total
Mercury, total
Molybdenum, total
Nickel, total
Selenium, total
Silver, total
Zinc, total
Cyanide, total
Category ThreeAny pollutants identified in F.1. and F.2. above.
Pollutant
Result
Unit
Category Four
Pretreatment standard pollutants of any industrial category identified in A.7. Contact Christian
Torres for the complete list of applicable pollutants. Attach laboratory report with results.
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Section G – Intent to Self Monitor
Please select one of the following options.
This facility elects to conduct self monitoring in order to determine compliance with site specific
numeric discharge limitations. Self monitoring will be completed in accordance with the applicable
terms and conditions of the issued Industrial Wastewater Discharge Permit and Article 923 of the
City’s Codified Ordinances.
This facility authorizes the City of Bethlehem to complete monitoring on its behalf in order to determine
compliance with site specific numeric discharge limitations. The facility will be responsible for all fees
associated with sampling and analysis as defined in the issued Industrial Wastewater Discharge
Permit. In the event that the facility may independently collect additional discharge monitoring data,
the data will be reported to the City of Bethlehem in accordance with the applicable terms and
conditions of the issued Industrial Wastewater Discharge Permit and Article 923 of the City of
Bethlehem’s Codified Ordinances.
Section H – Certification Statement
An authorized official, as described below, should sign this application after adequate completion and
review of the form.
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 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 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.
Authorized Representative Signature Date
Printed Name
Phone
Title
Email
Codified Ordinances of the City of Bethlehem Article 923.01(e) Authorized Representative of a User: an
authorized representative of a User may be:
(1) A president, secretary, treasurer, or 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.
(2) A general partner or proprietor, if the User is a partnership or proprietorship, respectively.
(3) A director or highest official appointed or designated to oversee operations and performance, if the
User is a Federal, State or Local Governmental facility.
(4) A duly authorized representative of the individual identified in (1) through (3) above, if such
representative is responsible for the overall operation of the facilities from which the indirect discharge
originates and a written request for designation of an alternate representative is approved by the City.
Please return completed applications to:
Mr. Christian Torres, MIPP/QC Coordinator
City of Bethlehem Wastewater Treatment Plant
144 Shimersville Road
Bethlehem, PA 18015
NOTE: The processing fee for the City of Bethlehem’s Industrial Waste Discharge Permit Application is
currently $250.00. Please include a check or money order payable to the City of Bethlehem in
the amount of $250.00 with this application. The City of Bethlehem will not review applications
without the processing fee and industrial wastewater discharges will be in violation of City of
Bethlehem Codified Ordinance 923.
click to sign
signature
click to edit
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Table I - EPA Priority Pollutants
PCBs & Pesticides
4,4-DDD endosulfan I PCB-1221
4,4-DDE endosulfan II PCB-1232
4,4-DDT endosulfan sulfate PCB-1242
aldrin endrin PCB-1248
alpha-BHC endrin aldehyde PCB-1254
beta-BHC gamma-BHC PCB-1260
chlordane heptachlor toxaphene
delta-BHC heptachlor epoxide
dieldrin PCB-1016
Volatile Organic Compounds (VOCs)
1,1,1-trichloroethane acrolein ethylbenzene
1,1,2,2-tetrachloroethane acrylonitrile methyl bromide
1,1,2-trichloroethane benzene methyl chloride
1,1-dichloroethane bromoform methylene chloride
1,1-dichloroethylene carbon tetrachloride tetrachloroethylene
1,2-dichloroethane chlorobenzene toluene
1,2-dichloropropane chlorodibromomethane trichloroethylene
1,2-trans-dichloroethylene chloroethane vinyl chloride
1,3-dichloropropylene chloroform
2-chloroethyl vinyl ethers dichlorobromomethane
Semivolatile Organic Compounds (SVOCs)
1,2,4-trichlorobenzene acenaphthene di-n-octyl phthalate
1,2-dichlorobenzene acenaphthylene fluoranthene
1,2-diphenylhydrazine anthracene fluorene
1,3-dichlorobenzene benzidine hexachlorobenzene
1,4-dichlorobenzene benzo(a) anthracene hexachlorobutadiene
2,4,6-trichlorophenol benzo(a) pyrene hexachlorocyclopentadiene
2,4-dichlorophenol benzo(b) fluoranthene hexachloroethane
2,4-dimethylphenol benzo(ghi) perylene indeno(1,2,3-cd) pyrene
2,4-dinitrophenol benzo(k) fluoranthene isophorone
2,4-dinitrotoluene bis(2-chloroethoxy) methane naphthalene
2,6-dinitrotoluene bis(2-chloroethyl) ether nitrobenzene
2-chloronaphthalene bis(2-chloroisopropyl) ether n-nitrosodimethylamine
2-chlorophenol bis(2-ethylhexyl) phthalate n-nitrosodi-n-propylamine
2-nitrophenol butyl benzyl phthalate n-nitrosodiphenylamine
3,3-dichlorobenzidine chrysene p-chloro-m-cresol
4,6-dinitro-o-cresol dibenzo(a,h) anthracene pentachlorophenol
4-bromophenyl phenyl ether diethyl phthalate phenanthrene
4-chlorophenyl phenyl ether dimethyl phthalate phenol
4-nitrophenol di-n-butyl phthalate pyrene
Metals/Miscellaneous
2,3,7,8-TCDD chromium selenium
antimony copper silver
arsenic cyanide, total thallium
asbestos lead zinc
beryllium mercury
cadmium nickel
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