SACRAMENTO REGIONAL COUNTY SANITATION DISTRICT (REGIONAL SAN)
Wastewater Discharge Permit Application
For assistance, call the Wastewater Source Control Section (916-875-6470) or BERC (916-874-2100).
Section A – Applicant Information
Date
SITE INFORMATION
Facility Name
Facility Address
City
Zip
Assessor Parcel Number (list all)
Legal Name, incl. Parent Co.
Type of Business Entity
Corporation
Limited Liability Company (LLC)
Limited Partnership (LP)
Discharge Start Date
Date Business
Operations Began
Days of Operation
Hours of Operation
Other
Number of Employees
MAILING/CONTACT INFORMATION
Mailing Name
Mailing Address
City
State
Primary Contact Name
Title
Phone
Fax
Zip
Email
Application Contact Name
Title
Phone
Fax
Email
BILLING INFORMATION
Billing Name
Billing Address
City
State
Primary Billing Contact Name
Title
Phone
Fax
Zip
Email
Office Use Only:
Regional San Infill
Regional San WDPA
Regional San New
SASD Relief
Page 1 of 5
SASD Expansion
City of Sac
Sump 2
West Sac
Folsom
Rev. 8/22/13
Section B – Business Description
List manufacturing or service processes (primary and secondary) at this facility
Products
Raw Materials
For Office Use Only:
Regional San WDPA
Zero Discharge Status
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Applicable Category ________
Rev. 8/22/13
Section C – Wastewater Characterization
Table 1: Summary of Total Sewer Discharges (see instructions)
Process (describe)
Wastewater
BOD (mg/L)
Discharge (gal)
Daily
Monthly
Avg Max
Max
Max
Domestic
180
TSS (mg/L)
TKN (mg/L)
Avg Max
Avg
Max
40
40
180
pH
Batch* or Flow Rate
(specify range) Continuous (gpm)
N/A
N/A
Pollutants/ Characteristics
N/A
N/A
* If batch discharge, complete table below.
gpm = gallons per minute
Table 2: Batch Discharges to Sewer
Batch Process
For Office Use Only:
# discharges per (indicate) day,
week, month, or year
Flow (gallons)
SIF Totals/Max Monthly: __________________
Volume per batch
Duration
BOD (lbs)
TSS (lbs)
TKN (lbs)
gpm
_________
_________
_________
________
Table 3: Wastewater Discharges
Process/Wastestream
Describe Water Source
Wastewater Discharged
to Sewer (gal/day)
Volume Discharged to
Other Location (gal/day)
Complete next column
Describe Discharge to Other
Location
Product
Cooling
Boiler
Water Treatment
Washdown
Irrigation
Domestic
Other wastestream (specify)
Other wastestream (specify)
Total
Regional San WDPA
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Rev. 8/22/13
Table 4: Pretreatment – List any equipment or process used to treat the wastewater prior to discharge, for example pH control, filters, separators
Process/Wastestream
Pretreatment Description
Section D – Process Wastes
Table 5: Disposal of Non-sewered Wastes (List all hazardous or non-hazardous wastes)
Type of Waste
Hazardous or Non-hazardous
Amount
Frequency
Waste Removed By
Section E – Chemical Use and Storage
Table 6: Onsite Chemical Use and Storage (attach additional sheets as necessary)
Chemical/Product Name
For Office Use Only:
Hazardous Ingredients from MSDS
Process in Which Chemical is
Used
Maximum
Amount Stored
Slug Control Plan Required
Regional San WDPA
Page 4 of 5
Rev. 8/22/13
Amount Used
Annually
Section F – Attachments
Attach the Following (see instructions):
1. Process Flow Diagram for all processes; include wastewater discharges
2. Site Layout Map (see instructions for list of required items)
3. A list of other regulatory permits (and corresponding agency) held by this facility per 40 CFR 403
4. Recent wastewater analytical data, if available
5. Signature Authorization Form
Section G – Notes Section
Add general notes in the space provided below.
Section H – Certification and Signature
Authorized signature and certification of application is required.
Printed Name
Title
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 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.
Signature
Date
Submit To
Sacramento Regional County Sanitation District (Regional San)
Wastewater Source Control Section (WSCS)
10060 Goethe Road
Sacramento, CA 95827
Phone: 916-875-6470
Fax: 916-854-9286
Email: WSCSPermittedUsers@sacsewer.com
Regional San WDPA
Page 5 of 5
Rev. 8/22/13