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TOWN OF HUDSON, NEW HAMPSHIRE INDUSTRIAL DISCHARGE AGREEMENT (Town of Hudson)

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8/12 - 1 - IPP Permit Application
Date Received:
Application No.:
Existing Permit No.
(If Applicable)
TOWN OF HUDSON, NEW HAMPSHIRE
INDUSTRIAL DISCHARGE AGREEMENT (IDA)
PERMIT APPLICATION
I hereby apply for a permit to discharge the waste(s) described herein to the public sewerage system in
the Town of Hudson, New Hampshire.
By filing this application, it is agreed that the applicant shall comply with the Sewer Use Ordinance of
the Town of Hudson and all applicable State and Federal Regulations. (Please print or type all responses
unless noted otherwise. If none, state “none”, if not applicable, please provide evidence that the question is
not relevant to your facility. All questions must be answered).
1.
DATE OF APPLICATION
2.
APPLICANT’S NAME (Property Owner or Owner’s Agent)
Name:
Title:
Address:
Telephone No.:
Fax:
Email:
3.
Tax Map Number:
Lot Number:
APPLICANT’S NAME
(Business Owner or Business Owner’s Agent - Permit Signing Official)
Name:
Title:
Business Name:
Address:
Telephone No.:
Fax:
Email:
Application No.
8/12 - 2 - IPP Permit Application
4.
5.
APPLICANT’S ON-SITE REPRESENTATIVE IN CHARGE OF WASTEWATER
DISPOSAL (Permit Contact Person)
Name:
Title:
Address
Email:
Telephone No.:
Fax:
ENGINEER OR AUTHORIZED AGENT PREPARING APPLICATION (IF
APPLICABLE)
Name:
Title:
Address:
Telephone No.:
Fax:
6.
LABORATORY PERFORMING WASTEWATER ANALYSIS
Name:
Address:
Telephone No.:
Fax:
Email:
7.
TYPE OF BUSINESS
(If Job Shop, Please Note):
8.
THE INDUSTRY GENERALLY WORKS
SHIFTS PER DAY.
9.
CURRENTLY, THIS INDUSTRY EMPLOYS
PEOPLE FULL TIME.
CURRENTLY, THIS INDUSTRY EMPLOYS
PEOPLE PART TIME.
AFTER THE PERMIT IS ISSUED,
THE INDUSTRY PLANS TO ADD
PEOPLE FULL TIME
PEOPLE PART TIME
Application No.
8/12 - 3 - IPP Permit Application
10.
CURRENTLY, THIS INDUSTRY WORKS THE
FOLLOWING DAYS: (Circle Applicable Days)
S M T W R F S
11.
THE INDUSTRY GENERALLY OPERATES
DURING THE FOLLOWING HOURS:
12.
SIC CODE NO.
INDUSTRIAL GROUP:
NAICS CODE NO.
13.
THE INDUSTRY HAS THE
FOLLOWING EXPANSION PLANS:
14.
PLEASE LIST ALL ENVIRONMENTAL PERMITS HELD BY OR FOR THE FACILITY.
(This should include Hazardous Waste Generator Identification Information.)
15.
DOES THE INDUSTRY PRETREAT INDUSTRIAL PROCESS WASTEWATER?
YES?
NO?
16.
APPLICABLE FEDERAL CATEGORICAL PRETREATMENT CATEGORY:
(If Any, if None, State “None”):
17.
BRIEFLY DESCRIBE PROPOSED PROCESS OR CHEMISTRY:
18.
IF THERE EXISTS MORE THAN ONE DISCHARGE LOCATION, PLEASE
DESCRIBE PROPOSED LOCATION OF DISCHARGE:
Application No.
8/12 - 4 - IPP Permit Application
19.
PLEASE COMPLETE THE FOLLOWING:
Average (gpd) Maximum (gpd)
Sanitary
Proposed Process
Other
Total Total
20.
DESCRIBE FREQUENCY OF PROCESS WASTEWATER DISCHARGES:
Process Name
Continuous,
Intermittent,
Batch Dump?
Volume
Frequency of
Batch
Dumps
Hours per day
of Continuous
Dumps
21.
IS ANY WATER CONSUMED IN THE PRODUCT(S)?
YES
NO
IF YES, _____________GPD
22.
IS ANY WASTEWATER DISCHARGED OTHER
THAN TO MUNICIPAL SEWER?
YES
NO
If yes, indicate NPDES Permit Number and provide copy
TYPE
AVERAGE VOLUME
WHERE DISCHARGED
23.
IS A FORMAL CAFETERIA PROVIDED ON-SITE?
YES
NO
24.
ARE SHOWERS PROVIDED IN THE FACILITY?
YES
NO
Application No.
8/12 - 5 - IPP Permit Application
25.
PLEASE LIST ALL CHEMICALS USED IN THE FACILITY, I.E.; PRODUCTION
CHEMICALS, DEGREASERS, CLEANING SOLVENTS, PRETREATMENT
CHEMICALS, ETC. (Attach Copies of MSDS Sheets)
RAW MATERIALS
AMOUNT
USED/YEAR
ESTIMATED % LOST TO
SEWER
(If None, indicate 0%)
26.
PLEASE ATTACH THE FOLLOWING LINE DIAGRAMS (Process and Pretreatment Flow
Sketches) SHOWING THE PROPOSED PRODUCTION AND PRETREATMENT
PROCESSES.
PROPOSED MANUFACTURING PROCESS FLOW SKETCH
Attached
PROPOSED PRETREATMENT PROCESS SKETCH
No Process
Discharge
Attached
27.
PROVIDE A SUMMARY OF THE PROCESS INFORMATION:
(Attach additional sheets as needed)
Product Produced
Average Rate of Production/Quantity of Services
Provided
Amount
Units
(See Below)
Time Basis
(Day, Week, Month,
Year)
Units: Pounds, Kilograms, Square Feet, Square Meters, Tons, Gallons, Liters, Barrels, Pieces or Units,
Bushels, or Other, please specify:_____________________
Application No.
8/12 - 6 - IPP Permit Application
28.
PLEASE ATTACH ANY ADDITIONAL INFORMATION WHICH MAY CLARIFY
THE PROCESS OR PRETREATMENT SYSTEM (MANUFACTURER’S PRODUCT
LITERATURE, CHEMICAL MSDS SHEETS, TOXICITY DATA, TREATABILITY
STUDIES, ETC.).
29.
PLEASE ATTACH COPIES OF WASTER USAGE DATA (Meter Log Sheet or Water
Bills) FOR THE PAST YEAR (If available).
30.
PLEASE ATTACH A DETAILED MAP OF THE SITE (AND BUILDING) SHOWING
THE PIPE SIZES AND APP
ROXIMATE LOCATION OF ALL SEWER
CONNECTIONS, DRAINS, OR OUTFALLS LEAVING THE BUILDING AND ALL
SAMPLING LOCATIONS. (If any process wastewater is discharged or proposed to be
discharged, this map should include location of water meters, flow meters, general layout
of internal plumbing, sampling stations or control manholes, monitoring equipment and
pretreatment facilities.) Include plan scale, north arrow, street names, river, pond, and
well locations and an outline of on-lot storage-disposal systems (septic
tank and
leachfield), municipal sewer, chemical storage areas, bulk chemical storage areas and
containment devices, flow arrows, and any other pertinent data.
31.
PLEASE PROVIDE THE FOLLOWING DISCHARGE FLOW METER DATA:
Manufacturer Model
Location
(Key to Plan)
Manufacturer Model
Location
(Key to Plan)
32.
PLEASE ATTACH A GENERAL SITE LOCATION MAP (LOCUS).
33.
PLEASE DESCRIBE ANY MEASURES TAKEN OR PLANNED TO REDUCE WATER USAGE
AND IMPLEMENT POLLUTION PREVENTION TECHNIQUES, IF ANY, SUCH AS; FLOW
RESTRICTERS, COUNTERCURRENT RINSES, RECYCLING OF NON-CONTACT COOLING
WATER, CHEMICAL SUBSTITUTIONS, AND POLLUTANT SOURCE REDUCTION.
34.
IS A SPILL PREVENTION CONTROL AND COUNTERMEASURE PLAN PREPARED FOR
THE FACILITY? (PETROLEUM RELATED)
NO
YES
IF YES, LIST DATE LAST REVISED:
IS A GENERAL CHEMICAL SPILL PLAN PREPARED FOR THE FACILITY?
NO
YES
IF YES, LIST DATE LAST REVISED:
Application No.
8/12 - 7 - IPP Permit Application
35.
PLEASE LIST ALL INFLUENT WATER SOURCES:
Estimated
Average Volume
(gpd)
Estimated
Maximum
Volume
(gpd)
Location of
Use
Hudson Water Utility:
Other:
(Well, River, Stream, Pond)
Other:
(Well, River, Stream, Pond)
36.
IS ANY WATER RECYCLED? IF SO, PLEASE DESCRIBE:
37.
DESCRIBE LIQUID AND/OR SOLID WASTES THAT ARE HAULED AWAY FOR
DISPOSAL:
Type of Waste
Waste Hauler
Disposal Site
Application No.
8/12 - 8 - IPP Permit Application
38.
IF ANY PROCESS WASTEWATER WILL BE DISCHARGED, PLEASE PROVIDE THE
FOLLOWING INFORMATION: (Including Requested Sampling Data. Attach copy of lab report.
Data for representative process may be submitted if proposed data is not yet available. Provide a brief
narrative explaining potential differences, if any):
IS ANY DISCHARGE DEFINED AS HAZARDOUS
WASTE BY NEW HAMPSHIRE OR EPA? YES NO
IF YES, PLEASE POVIDE DETAILS ON PAGE 12.
SAMPLE POINT (Describe)
SOURCE OF WASTEWATER
(Process-Key to Plan)
VOLUME
GALLONS/DAY
pH (daily range)
TEMPERATURE (daily range)
NAME OF PERSON COLLECTING SAMPLE:
Note: Samples should be representative of daily flow from industrial processes (flow proportional
composite samples, or if batch discharge, a grab sample may be utilized.) Temperature, pH, cyanide,
and oil and grease must be a series of 4 grab samples).
PARAMETER
CONCENTRATION (mg/l)
Biochemical Oxygen Demand (5 Day)
Suspended Solids
Temperature
Alkalinity (caustic)
pH
Fats, wax, oil & grease
Arsenic
Boron
Cadmium
Chromium (Total)
Chromium (Hexavalent)
Copper
Lead
Mercury
Nickel
Selenium
Silver
Zinc
Cyanides (Total)
Sulfates
Phenols
Total Toxic Organics
Chloroform
Carbon Disulfide
Application No.
8/12 - 9 - IPP Permit Application
PRIORITY POLLUTANT INFORMATION:
Indicate with an “X” the priority pollutants that are or will be utilized in the manufacturing
processes or generated as by-products which may be discharged to the sewer. Also, mark all
items known, suspected to be present or known not to be present in the facility as
appropriate. All parameters should be marked.
Chemical Compound
Suspected
or Known
Present in
Waste-
water
NOT
Suspected or
Known
Present in
Waste-water
Suspected or
Known
Present in
the Facility
NOT
Suspected or
Known
Present in the
Facility
Unknown
Whether
Present in
the Facility
or
Wastestream
(Will
Require
Follow-up)
001 Acenaphthene
002 Acrolein
003 Acrylonitrile
004 Benzene
005 Benzidine
006 Carbon tetrachloride
(tetrachloromethane)
007 Chlorobenzene
008 1,2,4-trichlorobenzene
009 Hexachlorobenzene
010 1,2-dichloroethane
011 1,1,1-trichloreothane
012 Hexachloroethane
013 1,1-dichloroethane
014 1,1,2-trichloroethane
015 1,1,2,2-tetrachloroethane
016 Chloroethane
018 Bis(2-chloroethyl) ether
019 2-chloroethyl vinyl ether
(mixed)
020 2-chloronaphthalene
021 2,4, 6-trichlorophenol
022 Parachlorometa cresol
023 Chloroform
(trichloromethane)
024 2-chlorophenol
025 1,2-dichlorobenzene
026 1,3-dichlorobenzene
027 1,4-dichlorobenzene
028 3,3-dichlorobenzidine
029 1,1-dichloroethylene
030 1,2-trans-dichloroethylene
031 2,4-dichlorophenol
032 1,2-dichloropropane
Application No.
8/12 - 10 - IPP Permit Application
Chemical Compound
Suspected
or Known
Present in
Waste-
water
NOT
Suspected
or Known
Present in
Waste-
water
Suspected or
Known
Present in
the Facility
NOT
Suspected or
Known
Present in the
Facility
Unknown
Whether
Present in
the Facility
or
Wastestream
(Will
Require
Follow-up)
033 1,2-dichloropropylene
(1,3-dichloropropene)
034 2,4-dimethylphenol
035 2,4-dinitrotoluene
036 2,6-dinitrotoluene
037 1,2-diphenylhydrazine
038 Ethylbenzene
039 Fluoranthene
040 4-chlorophenyl phenyl ether
041 4-bromophenyl phenyl ether
042 Bis(2-chloroisopropyl) ether
043 Bis(2-chloroethoxy) methane
044 Methylene chloride
(dichloromethane)
045 Methyl chloride
(dichloromethane)
046 Methyl bromide
(bromomethane)
047 Bromoform
(tribromomethane)
048 Dichlorobromomethane
051 Chlorodibromomethane
052 Hexachlorobutadiene
053 Hexachlorocyclopentadiene
054 Isophorone
055 Naphthalene
056 Nitrobenzene
057 2-nitrophenol
058 4-nitrophenol
059 2,4-dinitrophenol
060 4,6-dinitro-o-cresol
061 N-nitrosodimethylamine
062 N-nitrosodiphenylamine
063 N-nitrosodi-n-propylamine
064 Pentachlorophenol
065 Phenol
Application No.
8/12 - 11 - IPP Permit Application
Chemical Compound
Suspected
or Known
Present in
Waste-
water
NOT
Suspected
or Known
Present in
Waste-
water
Suspected or
Known
Present in
the Facility
NOT
Suspected or
Known
Present in the
Facility
Unknown
Whether
Present in
the Facility
or
Wastestream
(Will
Require
Follow up)
066 Bis(2-ethylhexyl) phthalate
067 Butyl benzyl phthalate
068 Di-N-Butyl Phthalate
069 Di-n-octyl phthalate
070 Diethyl Phthalate
071 Dimethyl phthalate
072 1,2-benzanthracene
(benzo(a) anthracene)
073 Benzo(a)pyrene (3,4-
benzo-pyrene)
074 Benzofluoranthene
(benzo(b) fluoranthene)
075 benzofluoranthene
(benzo(b) fluoranthene)
076 Chrysene
077 Acenaphthylene
078 Anthracene
079 Benzoperylene (benzo(ghi)
perylene)
080 Fluorene
081 Phenanthrene
082 Dibenzanthracene
(dibenzo(,h) anthracene)
083 Indeno (1,2,3-cd) pyrene
(2,3-o-pheynylene
pyrene)
084 Pyrene
085 Tetrachloroethylene
086 Toluene
087 Trichloroethylene
088 Vinyl chloride
(chloroethylene)
089 Aldrin
090 Dieldrin
091 Chlordane (technical
mixture and metabolites)
092 4,4-DDT
093 4,4-DDE (p,p-DDX)
094 4,4-DDD (p,p-TDE)
095 Alpha-endosulfan
096 Beta-endosulfan
097 Endosulfan sulfate
Application No.
8/12 - 12 - IPP Permit Application
Chemical Compound
Suspected
or Known
Present in
Waste-
water
Suspected
or Known
Present in
Waste-
water
Suspected or
Known
Present in
the Facility
NOT
Suspected or
Known
Present in the
Facility
Unknown
Whether
Present in
the Facility
or
Wastestream
(Will
Require
Follow up)
098 Endrin
099 Endrin aldehyde
100 Heptachlor
101 Heptachlor epoxide
(BHC-
hexachlorocyclohexane)
102 Alpha-BHC
103 Beta-BHC
104 Gamma-BHC (lindane)
105 Delta-BHC (PCB-
polychlorinated biphenyls)
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-tetrachloro-
dibenzo-p-dioxin (TCDD)
Application No.
8/12 - 13 - IPP Permit Application
39.
SIGNATURES
A.
PROFESSIONAL ENGINEER (Required if pretreatment system design and/or significant chemistry
designs are proposed.)
I certify that I have prepared this application and that to the best of my knowledge the information
herein provided is true, complete and accurate.
Engineering Firm
Engineer’s Signature
Engineer’s Name (Print or Type)
Professional Engineer’s Stamp
Date
B.
APPLICANT/AUTHORIZED AGENT (Required for all applications.)
I certify that I have personally reviewed and am familiar with this application. Based upon my inquiry
of those individuals immediately responsible for obtaining the information reported herein, I believe that
the submitted information is true, accurate and complete. I am aware that there are significant penalties
for submitting false information, including the possibility of fine and/or imprisonment.
_____________________________________
__________________________________________
Property Owner or Owner’s Agent (Signature)
Building Owner or Owner’s Agent (Signature)
_____________________________________
__________________________________________
Property Owner or Owner’s Agent
(Print or Type)
Building Owner or Owner’s Agent
(Print or Type)
_____________________________________
________________________________________
Date
Date
Confidentiality: Any claim for confidentiality may be made by stamping the words “Confidential Business
Information” on each page containing such information. Information relating to wastewater
discharge characteristics shall be available to the public without restriction. Other information
shall be available to the extent provided by 40 CFR Section 403.
Application No.
8/12 - 14 - IPP Permit Application
HUDSON INDUSTRIAL PRETREATMENT PROGRAM
NOTIFICATION OF HAZARDOUS WASTE DISCHARGED TO THE PUBLIC SEWER
Company Name:
Address:
Contact Person:
Title:
Telephone Number:
CHECK ONE:
No hazardous wastes discharged Hazardous wastes discharged
in reportable quantities already reported
The following hazardous wastes are or will be discharged to the public sewer:
HAZARDOUS WASTE INFORMATION (use additional sheets if necessary):
NAME OF WASTE:
EPA HAZARDOUS WASTE NUMBER:
TYPE OF DISCHARGE:
Continuous Batch Other:
HAZARDOUS WASTE INFORMATION:
If more than 100 kilograms of any hazardous waste per calendar month is discharged to the sewer, please include the
following items of information for each hazardous waste, to the extent such information is known and readily
available.
Name of
Constituent
Mass in
Wastestream
(this month)
Concentration on
Wastestream
(this month)
Mass in
Wastestream
(next 12 mos.)
I certify that I have a program in place to reduce the volume and toxicity of hazardous waste generated to a
degree I have determined economically practical.
Signature of Company Representative Date
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TOWN OF HUDSON, NEW HAMPSHIRE INDUSTRIAL DISCHARGE AGREEMENT (Town of Hudson)

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Completed 18 February 2021

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