WASTEWATER DISCHARGE QUESTIONNAIRE
FOUNTAIN SANITATION DISTRICT
SECTION A - GENERAL INFORMATION
Return the completed application by:
1.
Applicant Business Name
2.
Address of facility discharging wastewater: (if more
than one, use bottom of page)
Street
City
3.
State
Business Address:
Street
City
4.
5.
Zip
Mailing Address:
City
State
Zip
Chief Executive Officer
Name
Mailing Address
City
6.
Zip
Title
State
Zip
Person to be contacted about this application
Name
Title
Phone
7.
Person to be contacted in case of emergency
Name
Title
Day Phone
8.
Night Phone
CERTIFICATION: 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 ensure that
qualified personnel properly gather and evaluate the information submitted. Based on my inquiry
of the person or persons who manage the system or the 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 a fine and imprisonment for knowing violations.
Print Name
Title
Signature
Date
D:\687295503.doc
1
SECTION B - PRODUCT OR SERVICE INFORMATION
1.
Brief narrative description of the primary manufacturing or service activity at premise address and
the applicable Standard Industrial Code(s) (SIC No.):
2.
Principal Products At
Above Facility
QUANTITIES
PAST CALENDAR YEAR
Amounts Per Mo.
Avg.
ESTIMATED THIS CALENDAR
YEAR
Monthly
Max.
Amounts Per Mo.
Units
Avg.
Max.
Monthly
Units
3.
Raw Materials
At Above Facility
QUANTITIES
PAST CALENDAR YEAR
Amounts Per Mo.
Avg.
D:\687295503.doc
ESTIMATED THIS CALENDAR
YEAR
Monthly
Max.
2
Units
Amounts Per Mo.
Avg.
Max.
Monthly
Units
4.
Check all additional activities at your premises:










Electroplating
Flammables, Explosives
Food Preparation Service
Laboratory
Laundry, Cleaning
Machine Shop
Medical Care
Painting, Finishing
Paint or Ink Formulation
Coating









Photographic Processing
Plastics Processing
Printing
Repair Shop, Garage
Research
Rubber Processing
Steam/Power Generation
Warehousing
Other (specify)
SECTION C - PLANT OPERATIONAL CHARACTERISTICS
1.
Process Flow Mode:
 batch
 continuous
 both
If major process is Batch:
a.
b.
2.
c.
Number of batch discharges:
Time of batch discharges:
,
,
at
,
,
,(Hours of Day)
Describe average type batch & times
d.
Average quantity per batch:
per month
,(Days of Week)
gallons.
Variation of Operation
Indicate whether the business
activity is:

Continuous throughout the year, or

Seasonal -- Circle the months of the year during which discharge occurs:
J F M A M J J A S O N D
3.
Discharge period occurs daily:
Sun
Mon
Tues
Wed
Thur
From
To
D:\687295503.doc
3
Fri
Sat
4.
Wastewater Flow Rate
Peak Hourly
gallons/minute
If Operations Are Seasonal
Average Daily (gallons/day)
Max. Daily
gallons/day
Annual Daily Avg.
gallons/day
Day of Week Maximums Occur:
5.
Seasonal Min.
Month:
Seasonal Max.
Month:
Number of Employees per Shift
First Shift
Hours
No.
No.
Second Shift
Hours
No.
Third Shift
Hours
Weekday
to
to
to
Saturday
to
to
to
Sunday
to
to
to
Seasonal
to
to
to
SECTION D - WATER USE AND WASTEWATER DISCHARGED
1.
Water Use and Disposition -- Estimate the average quantity of water received and
wastewater discharged daily.
SUPPLY FROM
City of Ftn
Water Used For:
gal/day
DISCHARGED TO
Other
gal/day
Source
Sanitary
Processes*
Boiler
Cooling
Washing
Irrigation
Other
Total
D:\687295503.doc
4
FSD Sewer
gal/day
Other
gal/day
Disch. To
2.
* List average usage and average wastewater discharge from process above
Brief Process Description
Average Water
Consumption
(Gallons per day)
Estimated
Average Discharge
(gallons per day)
3.
Describe any water treatment or conditioning processes utilized:
4.
Describe any water recycling or material reclaiming processes utilized:
5.
Are any liquid wastes, sludges or other waste materials generated from your process(s) and not
disposed of in the sewer system?
Yes
No
If "no", skip questions 2 and 3
If "yes", complete questions 6 and 7.
6.
These other wastes not disposed of in the sewer system may best be described as:
Estimated Gallons or Pounds/Year
Acids and Alkalies
Heavy Metal Sludges
Inks/Dyes
Oils and/or Grease
Organic Compounds
Paints
Pesticides
Planting Wastes
Pretreatment Sludges
Solvents/thinners
Other Hazardous Wastes (Specify)
D:\687295503.doc
5
Other Wastes (Specify)
7.
8.
For the other wastes identified as present above, does your company practice:


on-site storage
on-site disposal; Method

off-site disposal;
Ultimate disposal site
Are any liquid wastes, sludges or other waste materials generated from your process(s) that are
disposed of in the sewer system?
Yes
No
If "no", skip questions 9 and 10
If "yes", complete questions 9 and 10.
9.
These wastes may best be described as:
Estimated Gallons or Pounds/Year
Acids and Alkalies
Heavy Metal Sludges
Inks/Dyes
Oils and/or Grease
Organic Compounds
Paints
Pesticides
Planting Wastes
Pretreatment Sludges
Solvents/thinners
Other Hazardous Wastes (Specify)
Other Wastes (Specify)
D:\687295503.doc
6
10.
Priority Pollutant Information
Company Name:
Premise Address:
Priority Pollutant Information: Please indicate by placing an "x" in the appropriate box by each listed
chemical whether it is "Suspected to be Absent", "Known to be Absent", "Suspected to be Present", or
"Known to be Present" in your manufacturing or service activity or generated as a by-product. Some
compounds are known by other names. Please refer to the instruction packet for those compounds which
have an asterisk (*).
ITEM CHEMICAL COMPOUND S
NO.
U
S
P
E
C
T
E
D
1.
aluminum.............................. 
2.
asbestos (fibrous) ................ 
3.
barium (total) ........................ 
4.
boron (total) .......................... 
5.
cobalt (total) ......................... 
6.
cyanide (total)....................... 
7.
antimony (total) .................... 
8.
arsenic (total) ....................... 
9.
berylium (total) ..................... 
10.
cadmium (total) .................... 
11.
chromium (total) ................... 
12.
copper (total) ........................ 
13.
cyanide (total)....................... 
14.
iron (total) ............................. 
15.
lead (total) ............................ 
16.
magnesium (total) ................ 
17.
mercury (total) ...................... 
18.
molybdenum (total) .............. 
19.
manganese (total) ................ 
20.
nickel (total) .......................... 
21.
phenols (total) ...................... 
22.
selenium (total) .................... 
23.
silver (total) ........................... 
24.
thallium (total)....................... 
25.
tin (total) ............................... 
26.
titanium (total) ...................... 
27.
zinc (total) ............................. 
28.
acenaphthene ...................... 
29.
acenaphthylene.................... 
30.
acrolein ................................. 
31.
acrylonitrile ........................... 
32.
acetaldehyde........................ 
33.
aldrin..................................... 
34.
allyl alcohol........................... 
35.
allyl chloride ......................... 
36.
amyl acetate ......................... 
37.
aniline ................................... 
38.
anthracene ........................... 
39.
benzene ............................... 
79. 2-chloronaphthalene................. 
D:\687295503.doc
A
B
S
E
N
T
K
N
O
W
N
A
B
S
E
N
T








































S
U
S
P
E
C
T
E
D
P
R
E
S
E
N
T








































K
N
O
W
N
P ITEM
R NO.
E
S
E
N
T








































40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
138.
7
CHEMICAL COMPOUND
S
U
S
P
E
C
T
E
D
benzidine .................................. 
benzo (a) anthracene* ............. 
benzo (a) pyrene* .................... 
benzo (b) fluoranthene............. 
benzonitrile ............................... 
benzo (g,h,i) perylene* ............. 
benzo (k) fluorathene*.............. 
benzyl chloride ......................... 
a-BHC (alpha) .......................... 
b-BHC (beta) ............................ 
d-BHC (delta) ........................... 
g-BHC* (gamma) ..................... 
bis(2-chloroethyl)ether* ............ 
bis(2-chloroethoxy)methane* ... 
bis(2-chloroisopropyl)ether* ..... 
bis(chloromethyl)ether* ............ 
bis(2-ethylhexyl)phthalate*....... 
bromide .................................... 
bromodichloromethane* .......... 
bromoform* .............................. 
bromomethane* ....................... 
4-bromophenylphenyl ether ..... 
butyl acetate ............................. 
butylamine ................................ 
butylbenzylphthalate ................ 
captan ...................................... 
carbaryl..................................... 
carbofuran ................................ 
carbon disulfide ........................ 
carbon tetrachloride* ................ 
chlordane ................................. 
chlorine (total residual)............. 
chlorobromomethane ............... 
4-chloro-3-methylphenol*......... 
chlorobenzene ......................... 
chloroethane* ........................... 
2-chloroethylvinyl ether ............ 
chloroform* ............................... 
chloromethane* ........................ 
ethylbenzene ............................ 
A
B
S
E
N
T
K
N
O
W
N








































A
B
S
E
N
T
S
U
S
P
E
C
T
E
D








































P
R
E
S
E
N
T
K
N
O
W
N








































P
R
E
S
E
N
T
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
133.
134.
135.
136.
137.
197.
198.
199.
2-chlorophenol* ........................ 
4-chlorophenylphenyl ether ...... 
chlorpyrifos ............................... 
chrysene* .................................. 
color .......................................... 
coumaphos ............................... 
cresol ........................................ 
crotonaldehyde ......................... 
cyclohexane.............................. 
2,4-D (2,4-dichlorophenoxyacetic acid ................................. 
4,4' - DDD* ................................ 
4,4' - DDE* ................................ 
4,4' - DDT* ................................ 
diazinon .................................... 
dicamba .................................... 
dichlobenil ................................. 
dichlone .................................... 
dibenzo(a,h)anthracene* .......... 
dibromochloromethane* .......... 
1,2-dichlorobenzene* ............... 
1,3-dichlorobenzene* ............... 
1,4-dichlorobenzene* ............... 
3,3'-dichlorobenzidine............... 
dichlorodifluoromethane* ......... 
1,1-dichloroethane* .................. 
1,2-dichloroethane* .................. 
1,1-dichloroethene* .................. 
trans-1,2-dichloroethene* ......... 
2,4-dichlorophenol .................... 
1,2-dichloropropane* ................ 
(cis&trans)1,3-dichloropropene*
2,2-dichloropropionic acid ........ 
dichlorvos.................................. 
dieldrin ...................................... 
diethyl amine ............................ 
dimethyl amine ......................... 
4-6-dinitro-o-cresol ................... 
diethylphthalate* ....................... 
2,4-dimethylphenol*.................. 
dimethyl phthalate .................... 
di-n-butyl phthalate ................... 
di-n-octyl phthalate* .................. 
dintrobenzene ........................... 
4,6-dinitro-2-methylphenol* ...... 
2,4-dinitrophenol ...................... 
2,4-dinitrotoluene ..................... 
2,6-dinitrotoluene ..................... 
1,2-diphenylhydrazine* ............ 
diquat ....................................... 
disulfoton.................................. 
diuron ....................................... 
endosulfan I* ............................ 
endosulfan II* ........................... 
endosulfan sulfate ................... 
endrin ....................................... 
endrin aldehyde ....................... 
epichlorohydrin ........................ 
ethion ....................................... 
phenol ...................................... 
phenolsufonate ........................ 
phosgene ................................. 
D:\687295503.doc























































































































































































8
139.
140.
141.
142.
143.
144.
145.
146.
147.
148.
149.
150.
151.
152.
153.
154.
155.
156.
157.
158.
159.
160.
161.
162.
163.
164.
165.
166.
167.
168.
169.
170.
171.
172.
173.
174.
175.
176.
177.
178.
179.
180.
181.
182.
183.
184.
185.
186.
187.
188.
189.
190.
191.
192.
193.
194.
195.
196.
219.
220.
221.
ethylene diamine ...................... 
ethylene dibromide................... 
fecal coliform ............................ 
fluoranthene ............................. 
fluorene* ................................... 
fluoride...................................... 
formaldehyde ........................... 
furfural ...................................... 
guthion ..................................... 
heptachlor ................................ 
heptachlor epoxide................... 
hexachlorobenzene* ................ 
hexachlorobutadiene ............... 
hexachlorocyclopenta-diene* 
hexachloroethane* ................... 
indeno(1,2,3-cd)pyrene* .......... 
isophorone* .............................. 
isoprene ................................... 
isopropanolamine ................... 
dodecylbenzenesulfonate ........ 
kelthane.................................... 
kepone ..................................... 
malathion.................................. 
mercaptodimethur .................... 
methoxychlor ............................ 
methyl bromide ........................ 
methyl chloride ......................... 
methyl mercaptan .................... 
methyl methacrylate ................. 
methyl parathion ...................... 
methylene chloride* ................. 
mevinphos ................................ 
mexacarbate ............................ 
monoethyl amine...................... 
monomethyl amine .................. 
naled......................................... 
naphthalene ............................. 
napthenic acid .......................... 
nitrate-nitrite ............................. 
nitrobenzene ............................ 
nitrogen .................................... 
2-nitrophenol ............................ 
4-nitrophenol* ........................... 
N-nitrosodimethylamine*.......... 
N-nitrosodi-n-propylamine*

N-nitrosodiphenylamine*

nitrotoluene .............................. 
oil and grease .......................... 
p-chloro-m-cresol ..................... 
PCB-1016* ............................... 
PCB-1221* ............................... 
PCB-1232* ............................... 
PCB-1242* ............................... 
PCB-1248* ............................... 
PCB-1254* ............................... 
PCB-1260* ............................... 
parathion .................................. 
pentachlorophenol ................... 
phenanthrene ........................... 
1,1,2,2-tetrachloroethane* ....... 
tetrachloroethane*.................... 
toluene* .................................... 


























































































































































































200.
201.
202.
203.
204.
205.
206.
207.
208.
209.
210.
211.
212.
213.
214.
215.
216.
217.
218.
phosphorus (total) .................... 
propargite ................................. 
propylene oxide ....................... 
pyrene ...................................... 
pyrethrins ................................. 
quinoline................................... 
radioactivity .............................. 
resorcinol ................................. 
strontium .................................. 
strychnine................................. 
stryene ..................................... 
sulfate ...................................... 
sulfide ....................................... 
sulfite ........................................ 
surfactants ............................... 
2,4,5-T...................................... 
TDE .......................................... 
2,4,5-TP ................................... 
2,3,7,8-tetrachlorodibenzo-p-dioxin* ........................ 
D:\687295503.doc

























































222.
223.
224.
225.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
238.
239.
9
toxaphene ................................ 
1,2,4-trichlorobenzene ............. 
1,1,1-trichloroethane*............... 
1,1,2-trichloroethane*............... 
trichloroethene* ........................ 
trichlorofan ............................... 
trichlorofluoromethane*............ 
2,4,6-trichlorophenol ................ 
triethanolamine
dodecylbenzenesulfonate ........ 
triethylamine ............................. 
Trimethylamine ........................ 
uranium .................................... 
vanadium.................................. 
vinyl acetate ............................. 
vinyl chloride* ........................... 
xylene ....................................... 
xylenol ...................................... 
zirconium .................................. 






















































For chemical compounds which are indicated to be "Known Present", please list and provide the
following data for each: (attach additional sheets if needed.)
ITEM
NO.
D:\687295503.doc
CHEMICAL
COMPOUND
ANNUAL
USAGE
(LBS)
ESTIMATED
LOSS TO
SEWER
(LBS/YEAR)
10
ITEM
NO.
CHEMICAL
COMPOUND
ANNUAL ESTIMATED
USAGE
LOSS TO
(LBS)
SEWER
(LBS/YEAR)
SECTION E - PRACTICES
1.
Is a Spill Prevention Control and Countermeasure Plan/Slug Control Plan prepared for the facility?
Yes
No
2.
If YES, attach copy. This plan should conform to the requirements of a slug control plan as set forth
in 40 CFR 403.8(f)(2)(v).
If NO sketch plant layout, show chemical storage areas, identify chemicals being stored and
indicate location in Part G.
3.
Pollution Abatement Practices
Wastewater Pretreatment -- Check the type of treatment, if any, given wastewater before it is discharged
to the community sewer:
none,
holding tank,
sedimentation,
chlorination, or
4.
grease trap,
pH adjustment,
oil and water separator,
biological treatment,
grinding,
screening,
other (list)
Description
Describe the loading rates, design capacity, physical size, etc. of each pretreatment facility checked
above. Attach a sketch of facility and indicate location in Part G.
5.
Planned Wastewater Pretreatment Improvements
Describe any changes in treatment or disposal methods planned or under construction for wastewater.
Please include estimated completion dates. Attach a sketch of proposed facility and indicate location in
Part G.
D:\687295503.doc
11
6.
Stormwater Area
Total Area in square feet exposed to stormwater and draining to sewer:
7.
sq. ft.
Is a manhole or cleanout present to sample plant wastewater prior to discharge to district sewer?
Yes
D:\687295503.doc
No
12
SECTION F - PROCESS SCHEMATIC FLOW DIAGRAM
Schematic Flow Diagram -- For each major activity in which wastewater is generated, draw a diagram of
the flow of materials and water from start to completed product, showing all unit processes generating
wastewater. Number each unit process having wastewater discharges to the community sewer. Use
these numbers when showing this unit process in the building layout in Section G.
D:\687295503.doc
13
SECTION G - BUILDING LAYOUT
Building Layout -- Draw to scale the location of each building on the premises. Show location of all water
meters, storm drains numbered unit processes (From Section F), community sewers and each side sewer
connected to the community sewers. Number each side sewer and show possible sampling locations.
Include all chemical storage areas inside and outside the building(s) and list chemicals being stored.
Submit Section G for EACH facility. An attached blueprint or drawing of the facilities showing the above
items may be substituted for a drawing on this sheet.
D:\687295503.doc
14