ZERO-DISCHARGE CERTIFICATION REPORT (ZDCR)
INSTRUCTIONS:
Fill out the ZDCR completely and accurately. Be sure to specify the reporting period, (i.e. 1st quarter 2010, 2nd quarter
2010, etc.). The original signed ZDCR shall be submitted to the District by the due dates specified in the Permittee's Industrial
Wastewater Zero-Discharge Permit. The Permittee should keep a copy of each completed ZDCR for their files.
The original signed ZDCR shall be returned to:
Dublin San Ramon Services District
Wastewater Treatment Facility
7399 Johnson Drive
Pleasanton, CA 94588
Attention: Environmental Compliance Section
Note: Enforcement actions including, but not limited to, Notice of Violations, may be taken against the Permittee for
late, incomplete, falsified and/or unsigned ZDCRs.
Reporting Period:
COMPANY NAME:
ADDRESS:
CITY:
I.
ZIP:
DOCUMENT SUBMISSION
A.
The Permittee shall submit copies of all Uniform Hazardous Waste manifests or
other documentation for any hazardous and/or non-sewerable wastes which were
transported off-site for disposal or recycling during the reporting period.
Also, the Permittee shall submit copies of all receipts for any hazardous and/or nonsewerable wastes which were recycled on-site or sold as product during the reporting
period.
Please check the appropriate section:

I have enclosed copies of all Uniform Hazardous Waste manifests and/or
receipts for the off-haul of hazardous and/or non-sewerable wastes for this
reporting period. I have also enclosed all receipts for the on-site recycling
and/or sales of hazardous and/or non-sewerable wastes for this reporting
period.

There were no hazardous or non-sewerable wastes which were transported
off-site, recycled on site, or sold as product during this reporting period.
B.
The Permittee may be required to submit copies of operations and/or maintenance
logs. Please check your current Permit to determine if this applies to your facility.
Please check the appropriate section:
II.

I have enclosed copies of the operations and/or maintenance log(s) which
documents the activities that occurred during this reporting period.

The facility's current Industrial Wastewater Zero-Discharge Permit does not
require the submittal of copies of operations and/or maintenance logs.
NOTIFICATION OF CHANGE
The Permittee shall notify the District regarding any process changes, operational changes,
treatment changes and/or changes in chemical usage, whether permanent or temporary, that
have the potential to cause the Permittee to violate the terms and conditions of its current
Industrial Wastewater Zero-Discharge Permit including, but not limited to, the discharge of
process wastewater.
Please check the appropriate section:
III.

I have included documentation of the changes that have been made at the facility
during the current reporting period.

No changes have been made at the facility during the current reporting period.
CERTIFICATION
"I certify that the above named facility has been in consistent compliance with the terms and
conditions of its Industrial Wastewater Zero-Discharge Permit and the District's Sewage Code
(Chapter 7, Article 3)."
"I also 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."
Company Officer:
G:\IW\PERMITS\ZDCR.DOC
Name:
Title:
Signature:
Date: