Dallas/Fort Worth International Airport
Environmental Affairs Department
INDUSTRIAL WASTE SURVEY
SECTION A: GENERAL INFORMATION
1.
Company Name:
________________________________________________
2.
Facility Contact:
________________________________________________
3.
Physical Address:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
4.
Mailing Address:
________________________________________________
(if different)
________________________________________________
________________________________________________
________________________________________________
5.
Phone Number:
________________________________________________
6.
When were operations begun at this location?
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________________________
7.
What is the average water usage for the entire facility (calculated from water
utility bills for the last 12 months)?
______________________________________Gallons/day
8.
What products are produced or services rendered? ________________________
__________________________________________________________________
__________________________________________________________________
9.
Please describe the basic manufacturing or industrial processes:
__________________________________________________________________
__________________________________________________________________
10.
Does this facility hold any environmental permits? ____ Yes
If yes, please list them below.
Agency
Number
__________
______________________________
__________
______________________________
__________
______________________________
SECTION C: WATER SUPPLY
1.
Water Source:
____ Private Well
____ Municipal Water Utility
What city?
____________________
____ Surface Water
__________________
____ Other (specify)
2
____ No
2.
Water service account number(s): ____________________________________
____________________________________
____________________________________
____________________________________
SECTION C: SEWER INFORMATION
1.a.
For an existing business:
Is the building presently connected to the public sanitary sewer system?
____ Yes
____ No
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1.b.
For a new business:
Will you be occupying an existing building?
____ Yes
____ No
If yes, will you be expanding it?
____ Yes
____ No
Have you applied for a building permit?
____ Yes
____ No
Will you be connected to the public sanitary sewer?____ Yes
____ No
SECTION D: Wastewater Discharge Information
1.
Does (or will) this facility discharge any wastewater other than domestic
wastewater from restrooms to the city’s sewer?
____ Yes
2.
the
____ No (please skip to Section E)
Please indicate the types of wastes (other than sanitary) that your facility has
potential to discharge to the sewer. Attach MSD sheets if available.
____
____
____
____
____
____
____
____
____
____
Cooling water
____ Boiler blowdown
Chemicals
____ Oils and/or greases
Pesticides
____ Solvents
Equipment cleaning
____ Laundry wastes
Rinse waters
____ Food processing
Photo/x-ray finishing wastes ____ Medical wastes
Acidic or alkaline wastes
____ Radioactive wastes
PCB’s
____ Stripping compounds
Equipment cooling
____ Groundwater remediation wastes
Other: ______________________________________________________
______________________________________________________
3.
Are there any onsite wastewater treatment/pretreatment facilities?
____ Yes
If yes, please describe:
____ No
__________________________________________
4
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
SECTION E: SIGNATURES
1.
Please check one of the following:
____ I am a representative of the industry being surveyed (please proceed to
2.a.).
____ I am a representative of the city or TRA (please proceed to 2.b.).
2.a.
Certification Statement, to be completed by an Industry Representative:
I have personally examined and am familiar with the information submitted in
this document and attachments. Based upon my inquiry of those individuals
responsible for obtaining the information reported herein, I believe that the
submitted information is true, accurate and complete.
______________________________________
Name of Industry Representative
______________________________________
Signature
2.b.
__________________
Date
How was the industry contacted?
____ Telephone
____ Inspection or meeting
____ Online
____ Other:
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______________________________
Who was contacted? ________________________________________________
Title:
Date of contact:
________________________________________________
_______________________
_________________________________
Name
____________________________________
Signature
Notes
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
________________________________________________
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