Document Number:
Document Title:
DWU-FRM-013-PALS.PTT
Approved By:
Maurice Akech
Description of Last
Change:
Initial Release
Revision Number:
Effective Date:
1
08/24/10
Periodic Compliance Report – Paving and Roofing
PERIODIC COMPLIANCE REPORT
PAVING AND ROOFING MATERIALS (TARS AND ASPHALT) POINT SOURCE CATEGORY
ASPHALT ROOFING SUB-CATEGORY
REPORTING PERIOD: ____________________________________ through ______________________________________
COMPANY NAME:
COMPANY ADDRESS:
PERMIT NUMBER:
S.I.C. NUMBER:
TYPE OF INDUSTRY:
DOCUMENTATION MUST BE SUBMITTED TO SUPPORT THE FIGURES PRESENTED IN THIS REPORT FOR
WATER USAGE VOLUMES AND POLLUTANT CONCENTRATIONS.
I. WATER CONSUMPTION-Gallons per Day (GPD) of Operation
a. Water Account Number
Average Daily Use
gallons per day
gallons per day
gallons per day
gallons per day
Total Water Consumed (GPD)
gallons per day
II. WATER USAGE-Gallons per Day (GPD) of Operation
Wastewater discharged to the sanitary sewer:
Daily Average GPD
Daily Maximum GPD
a. Process Wastewater
+
(include cleanup & wash down water)
b. Domestic Usage
+
gals.
gals.
gals.
gals.
c. Boiler Blowdown
+
gals.
gals.
d. Non-contact Cooling Water
+
gals.
gals.
e. Other Wastewater Generated (include wastewater received at this facility from outside sources)
Total Wastewater Discharged
Other water usages:
Water into product
+
gals.
gals.
+
gals.
gals.
=
gals.
gals.
+
gals.
gals
Paving and Roofing, Page 2
Evaporation loss
+
gals.
gals.
Discharges to other than sanitary sewer
+
gals.
gals.
Total Water Used
=
gals.
gals.
If the Total Water Used in Part II is greater or less than the Total Water Consumed in Part I please provide an explanation.
III. POLLUTANT REPORT
PAVING AND ROOFING MATERIALS (TARS AND ASPHALT) CATEGORY
SAMPLE SITE NAME
PLEASE ANALYZE AND REPORT FOR EACH SAMPLE SITE ONLY THE PARAMETERS ON THE FACILITY
WASTEWATER DISCHARGE PERMIT.
Parameter
PH
Total Suspended Solids (TSS)
Biochemical Oxygen Demand (BOD)
Cyanide
Arsenic
Cadmium
Chromium
Copper
Lead
Mercury
Nickel
Selenium
Silver
Zinc
Total Petroleum Hydrocarbon
Phenol
Oil and Grease (Floatable)
Sulfide
Temperature
Polychlorinated Biphenyls (PCB's)
Flash Cup
Acetone
Isopropyl Alcohol
Methyl Alcohol
Methyl Ethyl Ketone
Benzene
Ethylbenzene
Methylene Chloride
Toluene
Xylene
Average Concentration in mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
Maximum Concentration
in mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
mg/L
Paving and Roofing, Page 3
(IF THIS FACILITY UTILIZES MORE THAN ONE (1) SAMPLE SITE PLEASE ATTACH ADDITIONAL PAGES, ONE
PAGE FOR EACH SAMPLING LOCATION MUST BE SUBMITTED)
IV. SAMPLE SITE IDENTIFICATION:
End of Pipe
If end of pipe, give total amount of dilution water contributed.
End of Process
GPD
V. HAZARDOUS WASTE
Is hazardous waste generated at this facility?
YES
NO
If yes, list the following: USEPA RCRA ID NO.
TCEQ WASTE GENERATOR NO.
VI. STATEMENT OF COMPLIANCE.
I hereby certify that the EPA categorical pretreatment regulations which apply to this facility are currently being met, and all
required compliance documentation is being maintained on-site and is available for inspection.
Name of Authorized Representative
Signature of Authorized Representative
Title
Date
V. DOCUMENT 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 designated 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.
Name of Authorized Representative
Signature of Authorized Representative
Title
Date