Fillable PERIODIC COMPLIANCE REPORT (PCR) (City of Baton Rouge / Parish of East Baton Rouge)

Fill Online, Printable, Fillable, Blank PERIODIC COMPLIANCE REPORT (PCR) (City of Baton Rouge / Parish of East Baton Rouge) Form

Use Fill to complete blank online CITY OF BATON ROUGE / PARISH OF EAST BATON ROUGE (LA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PERIODIC COMPLIANCE REPORT (PCR) (City of Baton Rouge / Parish of East Baton Rouge)

On average this form takes 11 minutes to complete

The PERIODIC COMPLIANCE REPORT (PCR) (City of Baton Rouge / Parish of East Baton Rouge) form is 2 pages long and contains:

  • 2 signatures
  • 5 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Baton Rouge / Parish of East Baton Rouge

BROWSE CITY OF BATON ROUGE / PARISH OF EAST BATON ROUGE (LA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PERIODIC COMPLIANCE REPORT (PCR)
DEPARTMENT OF ENVIRONMENTAL SERVICES - PRETREATMENT DIVISION
City of Baton Rouge - Parish of East Baton Rouge, 345 Chippewa St., Baton Rouge, LA 70805
Telephone: (225) 389-5456 Fax: (225) 389-5640
For Pretreatment Division use only
Date Received:
Reviewed by:
Date Reviewed:
cc: Albert Leo N. dela Cruz, Ph.D., Environmental & Wastewater Pretreatment Manager Q:\CPEBR\PCRForm_2016.doc
Sarah Boudreaux, Environmental Coordinator Revised 09/2016
Page 1
INDUSTRIAL USER INFORMATION:
Facility Name:
Site Address:
Person completing
report:
Name: Title:
Company: Phone #:
Reporting Period:
From: To:
Industrial Users: Completion of the Periodic Compliance Report (PCR) is required by the Industrial User Permit issued to your
facility
1
. Refer to your permit, Part II for reporting requirements. To complete this form, please address every section on the front and
back, check all the boxes that apply, and submit all information as required. Record only the information FOR THIS REPORTING
PERIOD as specified in your permit. Failure to accurately complete this report may result in non-compliance with the City-Parish
pretreatment regulation.
COMPLIANCE STATUS:
Permit (CHOOSE ONE)
I hereby certify that the facility and operations are in compliance with the Industrial User Permit during this reporting period.
The facility and operations are NOT in compliance with the Industrial User Permit during reporting period. An explanation is attached.
Local/Federal Limits (CHOOSE ONE IF SAMPLES ARE COLLECTED)
All analytical and/or monitoring results are within the required applicable local/federal limits.
Analytical and/or monitoring results indicate violation(s) of required applicable local/federal limits. A separate sheet is attached listing the
violation (s), the reason for violation(s), and a description of corrective action(s) taken.
1
Reference City/Parish Ordinance Number 9195, Title 2, Chapter 5, Section 2:276.
2
Reference City/Parish Ordinance Number 9195, Title 2, Chapter 5, Sections 2:268.
3
Reference City/Parish Ordinance Number 9195, Title 2, Chapter 5, Sections 2:253.
Continue onto the next page
Certification Statement
(Required for all user report submittals
2
)
"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(s) 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."
________________________________ ______________________________ _________________
Signature of Authorized Representative
3
Title & Company Date
click to sign
signature
click to edit
Note: The following sections below are excerpts from Part 2-7 of the issued permit.
cc: Albert Leo N. dela Cruz, Ph.D., Environmental & Wastewater Pretreatment Manager Q:\CPEBR\PCRForm_2016.doc
Sarah Boudreaux, Environmental Coordinator Revised 09/2016
Page 2
A. Self-Monitoring Report (CHECK ONE)
All Self-Monitoring Reports have been completed as
required and documentation has been submitted on time*.
Attached is a summary report covering the PCR period.
Attached is a status report of Self-Monitoring Report(s)
NOT completed as of the date of this PCR.
*The documentation includes: State certified laboratory name, address, telephone
number; reporting limits; units; QA/QC data; completed Chain of Custody reports;
Signed Verification of Sample Collection and Handling Procedures Form and
Verification of Data Accuracy Form; Flow measurement reports
D. Notification of Changes (CHECK ALL THAT APPLIES)
Formal written notification has been submitted to DES for
any changes in facility operations or productions*.
Formal written notification has been submitted to DES for
changes in Hazardous Waste Usage or Introduction of New
Hazardous Waste in facility operations or productions.
There are NO changes in facility operations or productions
during this reporting period.
*This includes: changes in management key personnel, notification of shutdown periods
B. Operation & Maintenance (CHECK ALL THAT APPLIES)
All Operation & Maintenance Logs are maintained on-site
as required from the issued permit.
All copies of the manifests/receipts for off-haul of process
liquids, sludges or solids or hazardous wastes are
maintained on-site and submitted to DES as required.
There are NO Operation & Maintenance Logs or Manifests
maintained on-site during this reporting period. An
EXPLANATION is attached.
E. Special Approvals/Conditions (CHECK ONE)
I hereby certify that the facility and operations are in
compliance with the Special Approvals/Conditions
identified in the permit.
The facility and operations are NOT in compliance with the
Special Approvals/Conditions identified in the permit. An
EXPLANATION is attached.
There are NO Special Approvals/Conditions requirements
identified in the permit.
C. Accidental or Slug Discharge (CHECK ALL THAT APPLIES)
All Accidental or Slug Discharge incident(s) has been
reported to DES as required and documentation has been
submitted.
Attached is a status report of Accidental or Slug Discharge
incident(s) that causes UPSET or BYPASS as of the date of
this PCR.
There are NO Accidental or Slug Discharge incident(s)
during this reporting period.
F. Compliance Schedule (CHECK ONE)
All Compliance Schedule items have been completed ass
required and documentation has been submitted.
Attached is a status report of Compliance Schedule items
NOT completed as of the date of this PCR.
There are NO Compliance Schedule requirements in the
issued permit that is due during this reporting period.
Total Toxic Organics (TTO) Certification (CHECK ONE)
Does facility have an approved TTO Management Plan on file? If YES, sign certification below. If NO, leave it blank.
YES
NO
"Based on my inquiry of the person or persons directly responsible for managing compliance with the permit limitation
and/or pretreatment standard for Total Toxic Organics (TTO), I certify that, to the best of my knowledge and belief, no dumping of
concentrated toxic organics into the public sewer system has occurred since the filing of the last compliance report. I further certify
that this facility is implementing the TTO Management Plan submitted to and approved by the Industrial Pretreatment Program of
the Department of Environmental Services of the City of Baton Rouge-Parish of East Baton Rouge."
________________________________ ______________________________ _________________
Signature of Authorized Representative
3
Title & Company Date
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PERIODIC COMPLIANCE REPORT (PCR) (City of Baton Rouge Parish of East Baton Rouge)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document