EXHIBIT I
METRO WASTEWATER RECLAMATION DISTRICT
INDUSTRIAL WASTE QUESTIONNAIRE
1.
FACILITY NAME
MAILING ADDRESS
Street
City
State
Zip
Street
City
State
Zip
FACILITY LOCATION
INDIVIDUAL RESPONSIBLE FOR FACILITY OPERATION:
Name
Title
Phone Number
Title
Phone Number
INDIVIDUAL PROVIDING INFORMATION:
Name
2. TYPE OF BUSINESS:
(please check)
MANUFACTURING 
DISTRIBUTION
SALES


CAR WASH 
SERVICE

OTHER

DESCRIBE YOUR FACILITY’S ACTIVITY:
CHECK ALL ACTIVITIES OCCURRING AT YOUR PREMISES:
 Battery Manufacturing
 Paint or Ink Formulation
 Centralized Waste Treatment
 Painting, Finishing
 Coil Coating
 Pesticide Chemicals Manufacturing
 Copper or Aluminum Forming
 Pesticide Formulating, Packaging & Repackaging
 Electrical Component Assembly or Manufacturing
 Pharmaceutical Manufacturing
 Electroplating
 Photographic Processing
 Flammables, Explosives Use
 Plastics Manufacturing, Molding or Forming
 Inorganic Chemicals Manufacturing
 Porcelain Enameling
 Iron & Steel Manufacturing
 Printed Circuit Board Manufacturing
 Laboratory
 Printing & Publishing
 Meat and Poultry Products
 Pulp, Paper & Paperboard Manufacturing
 Metal Finishing (including electroless plating,
 Rubber Processing
 Soap and Detergent Manufacturing
anodizing, coating, chemical etching, etc.)
 Metal Molding & Casting
 Metal Products and Machinery
 Smelting
 Non-Ferrous Metals Forming
 Transportation Equipment Cleaning
 Non-Ferrous Metals Manufacturing
 Vehicle Repair Shop, Garage
 Steam/Power Generation
 Organic Chemicals, Plastics and Synthetic Fibers  None of listed activities
Manufacturing
M:\T&F\IWP\Survey\Industrial Waste Questionnaire_05-18-12.doc
(1)
ser – 05/12
LIST PRINCIPAL PRODUCTS OR SERVICES:
LIST RAW MATERIALS USED:
LIST PROCESSES INVOLVED:
STANDARD INDUSTRIAL CLASSIFICATION CODE(S) FOR MANUFACTURING AND SERVICE
INDUSTRIES (Refer to Final Page of Questionnaire):
3. METHOD OF WASTEWATER DISPOSAL (check):
MUNICIPAL SEWER 
SEPTIC TANK

HAUL

If answer is "Septic Tank," do not complete the remainder of this questionnaire.
TYPE OF WASTEWATER DISCHARGED INTO MUNICIPAL SEWER (check one or both):
DOMESTIC 
INDUSTRIAL

Note: "Domestic" wastewater includes wastewater produced from the non-commercial preparation of
food, or wastewater containing only human excrement and similar matter from the sanitary conveniences
of dwellings and commercial, industrial or institutional buildings. All other wastewater should be considered
"industrial."
4. DOES YOUR ACTIVITY INVOLVE THE USE OF ANY OF THE FOLLOWING:
(Place an "X" in the appropriate box)
Attach MSDS Sheets for Car Wash Soap & any other products discharged to sewer
CHEMICALS
YES NO
NOT
SURE
IF YES, PLEASE
IDENTIFY
TO
SEWER
(Y/N)
INKS/DYES/PAINTS
ACIDS
SOLVENTS (incl. cleaning solvents)
FLAMMABLES
EXPLOSIVES
CORROSIVES
CORROSION INHIBITORS (incl. cooling/boiler sys.)
GREASES/OILS
PESTICIDES
HERBICIDES
METALS, INORGANICS
PCB'S & RELATED COMPOUNDS
HALOGENATED ALIPHATICS
ETHERS
MONOCYCLIC AROMATICS
PHENOLS/CRESOLS
PHTHALATE ESTERS
POLYCYCLIC AROMATIC HYDROCARBONS
NITROSAMINES
NITROGEN CONTAINING COMPOUNDS
RADIOACTIVE ISOTOPES
5. IF ANY OF THE ABOVE CONSTITUENTS ARE DISCHARGED OR PROPOSED TO BE DISCHARGED
INTO THE PUBLIC SANITARY SEWER, INDICATE WITH (Y/N) IN THE FAR RIGHT HAND COLUMN
ABOVE.
M:\T&F\IWP\Survey\Industrial Waste Questionnaire_05-18-12.doc
(2)
ser – 05/12
6. DO THE CONTAINERS OF THE SOLUTIONS OR MATERIALS USED IN YOUR MANUFACTURING,
CLEANING, OR OTHER OPERATIONS BEAR ANY HAZARD WARNING LABELS? IF SO, PLEASE
INDICATE THE NAME OF SOLUTION OR MATERIAL AND ATTACH MSDS SHEETS.
7. IS YOUR WASTEWATER TREATED BEFORE IT LEAVES YOUR FACILITY? (circle) YES NO
(i.e., sediment interceptor, oil separator, etc.)
IF YES, WHAT KIND OF TREATMENT?
8.
ARE THERE EVAPORATIVE COOLING TOWERS, COOLING SYSTEMS, CHILLERS OR BOILERS
INSTALLED ON-SITE?
YES NO
If yes, please circle the type system(s) installed.
9. ARE THERE ANY FLOOR DRAINS IN THE WORK AREAS? (circle) YES NO
10. DO YOU ANTICIPATE ANY CHANGES IN OPERATION IN THE FUTURE? (circle) YES NO
If yes, please explain.
11. ESTIMATE THE TOTAL WATER USAGE AT YOUR BUSINESS.
SOURCE OF INFORMATION (check one)
Water Bill
Estimate
Other*
AVERAGE MONTHLY GALLONS
Winter
Summer
*Please explain.
12. ATTACH A COPY OF ANY CHEMICAL ANALYSES PERFORMED ON YOUR WASTEWATER FLOWS
WITHIN THE LAST THREE YEARS.
ANALYSES ATTACHED 
NO ANALYSES AVAILABLE

NOTE TO SIGNING OFFICIAL: In accordance with Title 40 of the Code of Federal
Regulations Part 403 Section 403.14, effluent data provided in this questionnaire shall be
available to the public without restriction. Any other information provided may be claimed
as confidential by the submitter. Such claim must be asserted at the time of submission
by stamping the words "Confidential Business Information" on each page containing
confidential data or information, or similarly identifying the information claimed as
confidential. Requests for confidential treatment of information shall be governed by
procedures specified in 40 CFR Part 2.
I HAVE READ THE ENCLOSED INFORMATION AND BELIEVE THAT IT IS ACCURATE AND CORRECT.
NAME
TITLE
SIGNATURE
M:\T&F\IWP\Survey\Industrial Waste Questionnaire_05-18-12.doc
DATE
(3)
ser – 05/12
STANDARD INDUSTRIAL CLASSIFICATION CODES (SIC #)
FOR MANUFACTURING AND SERVICE INDUSTRIES
SIC #
INDUSTRY GROUP
SIC #
SERVICES
491
492
493
721
8734
8731
8732
7384
7532
7538
7542
8011
8021
806
807
Electric Services
Gas Production and Distribution
Combination Electric, Gas, and Other
Utility Services
Laundry, Cleaning, and Garment
Services
Testing Laboratories
Commercial Physical Research
Commercial Non-Physical Research
Photofinishing Laboratories
Automotive Body, and Painting Shops
Automotive Repair Shops
Car Washes
Medical Offices
Dental Offices
Hospitals
Medical and Dental Laboratories
MANUFACTURING
INDUSTRY GROUP
MANUFACTURING (Cont'd)
PRINTING , PUBLISHING, AND ALLIED
INDUSTRIES
27
All categories
CHEMICALS AND ALLIED PRODUCTS
281
282
283
284
285
286
287
289
Industrial Inorganic Chemicals
Plastics Materials and Synthetic Resins,
Synthetic Rubber, Synthetic and Other
Man-made Fibers, except Glass
Drugs
Soap, Detergents, and Cleaning
Preparations, Per-fumes, Cosmetics, and
Other Toilet Preparations
Paints, Varnishes, Lacquers, Enamels,
and Allied Products
Industrial Organic Chemicals
Agricultural Chemicals
Miscellaneous Chemical Products
FOOD AND KINDRED PRODUCTS
201
202
203
204
205
206
207
208
209
Meat Products
Dairy Products
Canned and Preserved Fruits and
Vegetables
Grain Mill Products
Bakery Products
Sugar and Confectionery Products
Fats and Oils
Beverages
Miscellaneous Food Preparations and
Kindred Products
TOBACCO MANUFACTURES
21
All categories
TEXTILE MILL PRODUCTS
22
All categories
APPAREL AND OTHER FINISHED
PRODUCTS MADE FROM FABRICS AND
SIMILAR MATERIALS
23
All categories
LUMBER AND WOOD PRODUCTS,
EXCEPT FURNITURE
2491
24
Wood Preserving, Particleboard
All other categories
PETROLEUM REFINING AND RELATED
INDUSTRIES
291
295
299
RUBBER AND MISCELLANEOUS
PLASTICS PRODUCTS
301
302
3052
306
308
311
31
2679
Tires and Inner Tubes
Rubber and Plastics Footwear
Rubber and Plastics Hose and Belting
Fabricated Rubber Products, not
elsewhere classified
Miscellaneous Plastics Products
Leather Tanning and Finishing
All other categories
STONE, CLAY, GLASS AND CONCRETE
PRODUCTS
32
343
344
345
346
347
348
349
Metal Cans and Shipping Containers
Cutlery, Hand Tools, and General
Hardware
Heating Equipment, Except Electric and
Warm Air; and Plumbing Fixtures
Fabricated Structural Metal Products
Screw Machine Products, and Bolts, Nuts,
Screws, Rivets, and Washers
Metal Forgings and Stampings
Coating, Engraving, and Allied Services
Ordnance and Accessories, Except
Vehicles and Guided Missiles
Miscellaneous Fabricated Metal Products
MACHINERY, EXCEPT ELECTRICAL
353
354
355
356
357
358
359
Engines and Turbines
Farm and Garden Machinery and
Equipment
Construction, Mining, and Materials
Handling Machinery and Equipment
Metalworking Machinery and Equipment
Special Industry Machinery, Except
Metalworking Machinery
General Industrial Machinery and
Equipment
Office and Computing Equipment
Refrigeration and Service Industry
Machinery
Miscellaneous Industrial and Commercial
Machinery and Equipment
ELECTRICAL AND ELECTRONIC
MACHINERY, EQUIPMENT, AND
SUPPLIES
362
363
364
365
366
367
369
All categories
Electric Transmission and Distribution
Equipment
Electrical Industrial Apparatus
Household Appliances
Electric Lighting and Wiring Equipment
Household Audio and Video Equipment,
and Audio Recordings
Communication Equipment
Electronic Components and Accessories
Miscellaneous Electrical Machinery,
Equipment, and Supplies
PRIMARY METAL INDUSTRIES
TRANSPORTATION EQUIPMENT
331
37
334
Pulp Mills
Paper Mills, Except Building Paper Mills
Paperboard Bills
Paperboard Containers and Boxes
Converted Paper and Paperboard
Products, Except Containers and Boxes
Converted Paper and Paperboard
Products, not elsewhere classified
341
342
361
25
251
262
263
265
267
FABRICATED METAL PRODUCTS,
EXCEPT MACHINERY AND
TRANSPORTATION EQUIPMENT
LEATHER AND LEATHER PRODUCTS
332
333
PAPER AND ALLIED PRODUCTS
Petroleum Refining
Asphalt Paving and Roofing Materials
Miscellaneous Products of Petroleum
and Coal
INDUSTRY GROUP
MANUFACTURING (Cont'd)
351
352
FURNITURE AND FIXTURES
All categories
SIC #
335
336
339
Blast Furnaces, Steel Works, and Rolling
and Finishing Mills
Iron and Steel Foundries
Primary Smelting and Refining of Nonferrous Metals
Secondary Smelting and Refining of
Non-ferrous Metals
Rolling, Drawing, and Extruding of Nonferrous Metals
Nonferrous Foundries (Castings)
Miscellaneous Primary Metal Products
All categories
MEASURING, ANALYZING, AND
CONTROLLING INSTRUMENTS;
PHOTOGRAPHIC, MEDICAL, AND
OPTICAL GOODS; WATCHES AND
CLOCKS
38
All categories
EJ
M:\T&F\Survey\IWQ_12-08.doc – kmu 06/11
HAZARDOUS WASTE DISCHARGE REPORTING
This notification is intended to provide information to users in the Metro Wastewater Reclamation
District's service area who discharge industrial wastewaters to the sanitary sewer system of their
obligations under 40 CFR 403.12. The District's service area includes Arvada, Aurora, Denver,
Edgewater, Lakewood, Mountain View, Thornton, Wheat Ridge, and parts of Englewood and
Westminster, as well as numerous water and sanitation districts in the metro Denver area.
a.
Within 180 calendar days of commencing any discharge to the POTW of a substance,
which, if otherwise disposed of, would be a hazardous waste under 40 CFR Part 261, the
industrial user shall notify in writing the Metro District, the Regional Waste Management
Director of the Environmental Protection Agency, and the Hazardous Materials and Waste
Management Division Director of the Colorado Department of Public Health and
Environment.
This notification must include the following information:
1)
2)
3)
The name of the hazardous waste as set forth in 40 CFR Part 261.
The EPA hazardous waste number.
The type of discharge (continuous, batch or other).
If the industrial user discharges more than 100 kilograms of such waste per calendar
month to the POTW, the notification shall also:
4)
5)
6)
Identify the hazardous constituents contained in the wastes.
Estimate the mass and concentrations of such constituents in the wastestream
discharged during that calendar month.
Estimate the mass of constituents in the wastestream expected to be discharged
during the following twelve months.
Any notification required by this section needs to be submitted only once for each
hazardous waste discharged.
b.
The industrial user is exempt from the requirements of Paragraph a, above, during a
calendar month in which it discharges no more than 15 kilograms of hazardous wastes,
unless the wastes are acute hazardous wastes as specified in 40 CFR 261.30(d) and
261.33(e). Discharge of more than 15 kilograms of non-acute hazardous wastes in a
calendar month, or of any quantity of acute hazardous wastes, requires one-time
notification, as specified above.
Subsequent months in which the industrial user discharges more than such quantities of
any hazardous waste do not require additional notification.
c.
In the case of any new regulations under Section 3001 of the Resource Conservation and
Recovery Act (RCRA) identifying additional characteristics of hazardous waste or listing
any additional substance as hazardous waste, the industrial user must notify the same
agencies described above of the discharge of such substance within 90 calendar days of
the effective date of the new regulations.
d.
In the case of any notification made pursuant to this section, the industrial user shall certify
that it has a program in place to reduce the volume and toxicity of hazardous wastes
generated to the degree it has determined to be economically practical.
HazWasteNotice_Nonpermitted.doc
04/2002_re
Nonylphenol Notice
Nonylphenol (NP), the starting material and breakdown product of a widely used surfactant,
nonylphenol ethoxylate (NPE), is nearly ubiquitous in the environment. The surfactant, NPE, is
typically used in commercial and industrial laundry detergents, cleaners and soaps; textile
processing; leather processing; pulp and paper manufacturing; paints; and as a dispersing
agent in pesticides and herbicides.
As a result of extensive studies and research, the Environmental Protection Agency (EPA)
determined NP to be extremely toxic to aquatic organisms and their environment and, as such,
established water quality standards for NP at the national level. Colorado’s Water Quality
Control Commission (WQCC) has adopted EPA’s water quality standard for NP of 6.6 parts per
billion, with an effective date of January 1, 2011.
Businesses or establishments that use products containing NP or NPE may have the potential
to violate requirements of the Metro Wastewater Reclamation District’s Rules and Regulations.
Specifically, Section 6.13.15, of the Rules and Regulations prohibits the discharge of any
substance which may cause the District to violate its National Pollutant Discharge Elimination
System (NPDES) Permit or the receiving water quality standards.
The Metro District recognizes the need for surfactants in the formulation of many products.
However, there are alternative chemicals that can be used in formulations other than NP and
NPE. The Metro District is asking businesses to check their chemical inventories or contact
their chemical manufacturer to determine whether or not chemicals utilized at their facility
contain NP or NPE (chemical list attached). Businesses that use NP or NPE containing
products are asked to select alternative products for use at their facility.
Unless users reduce or eliminate the discharge of these compounds, it will be necessary for the
Metro District to implement a limit for the amount allowed to be discharged to the sanitary
sewers or prohibit the discharge entirely. Each user would be required to demonstrate
compliance with the limit or prohibition.
The Metro District is the wastewater treatment facility for most of the Denver metropolitan area
and it administers a metro area program for the control of industrial waste discharges to the
sanitary sewer system, known as the Pretreatment Program. All businesses, including
industrial, commercial and governmental establishments, are subject to the requirements of the
Pretreatment Program. We are dedicated to protecting our environment and complying with all
applicable regulations, therefore, we ask for the cooperation of businesses and establishments
to assist in the elimination of these compounds in sanitary sewer discharges to enable us to
comply with the adoption of this water quality standard.
Contact Lori Maag (303-286-3434) or Pat Dowell (303-286-3267), Industrial Waste Supervisors
for the Metro District’s Pretreatment/Industrial Waste Control Program, for additional
information.