Wastewater Discharge Application SC007
23262 Township Road 540
Fort Saskatchewan, Alberta T8L 4A2
Tel: (780) 467-8655; Fax: (780) 467-5398
Web: www.acrwc.ab.ca
How to Submit the Application:
Choose one of the following:
1.
Complete the Application and fax it, along with any attachments, to Alberta Capital Region
Wastewater Commission; Attention Technical Services Group; at 780 467 5398;
2.
Complete the Application and email it, along with any attachments, to discharge@acrwc.ab.ca
How to Fill in the Application Form:

Provide all applicable information and attachments as required

If you do not have an answer for the requested information, indicate so and explain why.
 Indicate “N/A” if a section does not apply to your application

Use additional pages, if necessary.

Please print clearly if filling out the form in that manner

Please indicate what material has been attached to ensure that the ACRWC is aware of all the information provided.
Revision Date: June 21, 2010
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Wastewater Discharge Application SC007
1 Requesting Company Name:
2 Site Information
Discharge Site Address:
Town/City/County:
Postal Code:
Contact Information
Contact Person & Title:
Company Name:
Business Mailing Address:
Town or City: Postal Code:
Email:
3. Owner of property (if different from Company listed above)
Company Name (if applicable):
4 General Site Operation Information
Number of Employees involved in
Plant: Office: Other: Total:
Number of Shifts per day: Number of operating days per week:
5 Description of Product(s) or Service
Include North American Industry Classification System (NAICS):
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Wastewater Discharge Application SC007
6 Description of the Process(es) used in the Manufacturing or Servicing
Include raw materials used, products produced and the processes that generate the wastewater. Also include characteristics such as Batch (how many per time period), Continuous, or Both (explanation to be provided),
Seasonal Production Cycles, Specific Clean-up Periods and Clean-up Activities, Production Rates.
Please specify the operating period for your operation (when process wastewater is/will be discharged to the sewer);
Hours/Day Days/Week Weeks/Year
Specify the typical number of hours of discharge of process wastewater discharge to the sewer during the following shifts:
08:00 to 16:00 16:00 – 24:00 00:00 – 08:00
7 Average Daily Water Use and Sources
Municipal Supply Yes / No
Surface Water** Yes / No
Groundwater* Yes / No
Other sources** Yes / No m3/day Estimated or Measured m3/day Estimated or Measured m3/day Estimated or Measured m3/day Estimated or Measured
If flow rate varies significantly provide peak flow rates per day and month and explanation.
* Provide copy of the Permit to Take Water [ or other documentation per relevant jurisdictional requirements ]
** If ‘Yes’ - provide explanation as an attachment.
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Wastewater Discharge Application SC007
8 Discharge Points from Site
List all liquid effluent discharge points from the site, indicate whether the flow is continuous or batch, and record the average daily flow (estimate if no flow data is available) for each point in cubic meters per day of sanitary, noncontact cooling water, process wastewater, contact cooling water, boiler blow-down water, storm water, ground water and other discharge water to the sanitary sewer,
For example: process wastewater from manufacturing line to sanitary sewer continuously at an average daily flow of 200 m3/day (measured)
Identify each source on a schematic flow diagram (refer to section 19) and site layout, if necessary.
Source
#
Wastewater Source Description Continuous or Batch
Avg. Daily Volume (m3)
(Indicate Measured OR Estimated)
Total
9 Known Characteristics of Discharges
Provide existing data on the chemical composition and constituent concentrations of the discharges listed above in #8
Please fill the following table on the concentrations of specific parameters in the wastewater prior to discharge to sewer, or attach an analysis report. If analysis for a parameter has not been done or is not applicable, enter
“unknown”.
Concentration
BOD
5
Parameters
(mg/L)
COD (mg/L)
Oil and grease (mg/L)
TSS (mg/L)
TKN (mg/L)
Total Phosphorus (mg/L)
Concentration Parameters
Lead (mg/L)
Mercury (mg/L)
Molybdenum (mg/L)
Nickel (mg/L)
Silver (mg/L)
Sulfide (mg/L) pH
Arsenic (mg/L)
Cadmium (mg/L)
Chlorine (free)
Chromium (Total) (mg/L)
Thallium (mg/L)
Zinc (mg/L)
Hydrocarbons
Total Phenols (mg/L)
Temperature (

C)
Chromium (Hexavalent)
(mg/L)
Cobalt (mg/L)
Copper (mg/L)
Cyanide
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Wastewater Discharge Application SC007
10 Physical Layout / Flow Diagrams / Photograph of Sampling Point(s)
Provide the following items as attachments to this application:
 Simple sketch of property (to scale or approximate), with directional north arrow, showing
buildings, pretreatment works, property boundaries, effluent lines, discharge points and connections to
sanitary, combined and storm sewers. Also include locations of any monitoring equipment (flow meter, pH,
conductivity, etc.) and sampling points/sampler locations.
 Flow diagram of the site flows/processes is also required for each process that generates wastewater
 Photograph of sampling point(s)
11 Approval to Operate Information
Provide the Approval # for any Approval to Operate that the site may have under the requirements of the governing jurisdiction (i.e. Alberta Environment Approval to Operate).
12 Over Strength Surcharge Agreements (OSSA)
Does the site have an existing OSSA with the ACRWC or Municipality? Yes / No
Did the site previously have an OSSA with the ACRWC or Municipality? Yes / No
If Yes to either question - Attach a copy of each agreement to this form
13 Pretreatment of Discharges Prior to Discharge
Does the site have any pretreatment systems for process effluents prior to discharge to the sewer system?
Yes / No
If Yes, provide a description of the pretreatment systems and associated processes, design capacities, contaminants removed, estimated removal efficiency, performance objectives, provisions to bypass the pretreatment facilities, collection and disposal of any treatment byproducts (i.e. solid wastes/sludge) and operational procedures for the devices.
If necessary, identify each treatment process on a schematic flow diagram and site layout (refer to section 19).
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Wastewater Discharge Application SC007
14 Does the site have any of the following programs addressing discharges to the sewer system in place?
Pollution Prevention Yes / No
Best Management Plan Yes / No
Environmental Management System Yes / No
Water Conservation Yes / No
Other program / practices Yes / No
If yes - attach copy of each to the form and explanation for implementation.
15 Spill Prevention and Emergency Storage
Please summarize any storage or provision to prevent spills/wastewater from entering the sewer system without pretreatment.
16 Flow Information
Requested Total Discharge Flow Rates:
Maximum daily discharge rate:
Average daily discharge rate:
Maximum hourly discharge rate:
Discharge duration (if different from Section 6):
Hours/day Days/week m m m
3
3
3
/day
/day
/hour
Weeks/year
17 Requested Permit Term
Please indicate in the appropriate box below the length of time that you will require a Wastewater Discharge
Permit.
One time discharge
Less than 7 days
Less than 1 year
Ongoing/permanent
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Wastewater Discharge Application SC007
18 Method of Discharge
Please indicate in the appropriate box below the way how the wastewater will be discharged, if the application is approved.
Through existing sewer connection
By a new sewer connection
Through a transfer station.
If transfer station selected, please indicate which wastewater transfer station will be used and the name of the Hauled Waste
Trucking Company:
Note:
There are 5 wastewater transfer stations in the Region:

Leduc County Nisku Sewage Transfer Station: located near the intersection of 20 th Avenue
(Township Rd. 504) and 9 th Street (Range Rd. 250);

Parkland County Sewage Transfer Station #1: located near Highway16 and Highway 799;

Parkland County Sewage Transfer Station #2: located near the intersection of Highway 16 and
Highway 44;

Strathcona County Cloverbar Transfer Station: located on Range Road 232;

Sturgeon County Sewage Transfer Station: located in W4 Industrial Park of Sturgeon County.
If the ACRWC approves this application and the Strathcona Transfer Station is being utilized, another approval is required from Strathcona County. The ACRWC will forward the Approval Permit and wastewater quality data to the County for their review.
Date form completed:
Name and Title of Company Representative:
Signature of Authorized Company Representative:
The information submitted in this form may subject to verification by the ACRWC:
For ACRWC use only Date completed form received:
Date information verified/approved:
Revision Date: June 21, 2010
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