BUTLER COUNTY WATER AND SEWER DEPARTMENT
APPLICATION FOR AUTHORIZATION
TO DISCHARGE SPECIAL WASTEWATER
(Underground Storage Tanks)
Note to Property Owner / Signing Official
Information and data obtained from applications, permits, monitoring programs and inspections shall be
available to the public or any government agency without restriction unless it can be demonstrated that
the release of such information is entitled to the protection afforded by 40 CFR 403.14 entitled
“Confidentiality”. Submission of this application form does not constitute permission to discharge
wastewater. Separate discharge authorization documentation will be issued.
SECTION A- GENERAL INFORMATION
1.
Organization Requesting the Evaluation (e.g. Consulting Firm)
A. Requestor’s Name: ________________________________Telephone: (___)________
B. Organization:____________________________________________________________
C. Mailing Address: _________________________________________________________
________________________________________________________
2.
Location of Wastewater to be Discharged
A. Address: ________________________________________________________________
________________________________________________________________
3.
Current Property Owner
A. Contact Name: ___________________________________Telephone: (___)__________
B. Company Name:_________________________________________________________
C. Mailing Address: _________________________________________________________
_________________________________________________________
SECTION B- WASTEWATER CHARACTERIZATION
All industrial wastewater discharges shall be in compliance with the Butler County Sewer Use Rules.
Wastewater shall be discharged to an approved sanitary sewer location on the premises of the property.
Wastewater discharges to storm sewers cannot be authorized by the Butler County Water and Sewer
Department.
1.
Proposed Wastewater Discharge
A. Source Description: _______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
B. Sewer Description:________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
C. Quantity: ___________________ gallons
D. Flowrate: ___________________ gallons per minute
E. Type of discharge: One Time

On-going

F. Expected Duration: _______________________________________________________
G. Type of Pretreatment: _____________________________________________________
2.
Wastewater Analyses
The following pollutant concentrations shall be determined from a representative sample
(grab type) in accordance with Ohio Environmental Protection Agency approved methods.
Pollutant
Total Lead
Oil & Grease, Total Recoverable
Total Petroleum Hydrocarbons
pH
*Ethyl-Benzene
*Xylene
*Toluene
*Benzene
Notes:
Laboratory analytical reports shall be submitted with Application.
Additional analyses may be required as considered necessary.
*Levels should be below the Bureau of Underground Storage Tank Regulations (BUSTR)
action levels.
I have personally examined and am familiar with the information submitted in this document and
attachments. Based upon my inquiry of those individuals immediately responsible for obtaining the
information reported within, I believe that the submitted information is true, accurate and complete.
_____________________________________________
Signature of Property Owner or Signing Official
_______________
Date