Non-Domestic Discharge Permit – Allendale Charter Township

Allendale Charter Township Non-Domestic Discharge Permit

Application For Non-Domestic Discharge Permit

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GENERAL INFORMATION

Business Name

Name (Owner/Manager/Contact Person)

Phone

Mailing address for correspondence

Street Address Address Line 2 City State ZIP Code

Business Name

Legal address, Tax ID, or parcel number of property discharging to sewer system

Street Address Address Line 2 City State ZIP Code

Name and Title of Person Completing Permit

Phone

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.

Authorized Representative Signature (Responsible for the discharge)

Authorized Representative Title

Date

A. Nature of the business

B. IPP Permit Reissuance, no modifications?

Yes

N/A

C. Is this new construction?

Yes

D. Is this for a remodeling or addition?

Yes

E. Is this for a change of use?

Yes

F. Is this for the 5 year questionnaire?

Yes

G. Is this a multi-tenant space?

Yes

H. If yes how many tenant spaces?

*Note that multi-tenant spaces are required to install two separate sewer lines in the building. One line will be for sanitary sewage and the other for process waters. The process line will be brought outside each tenant space. Each tenant space is required to submit an individual IPP application.

1. Business Activity

Aluminum Forming

Metal Finishing

Nonferrous Metals Forming and Metal Powders

Organic Chemicals, Plastics and Synthetic Fibers

Paving and Roofing Materials (Tars and Asphalt)

Petroleum Refining

Rubber Manufacturing

Steam Electric Power Generating

Battery Manufacturing

Carbon Black Manufacturing

Copper Forming

Electroplating

Glass Manufacturing

Grain Mills

Inorganic Chemicals Manufacturing

Leather Tanning and Finishing

Metal Molding and Casting

Nonferrous Metals Manufacturing

Paint Formulating

Pesticides Chemicals

Pharmaceutical Manufacturing

Porcelain Enameling

Pulp, Paper, and Paperboard Manufacturing

Soap and Detergent Manufacturing

Timber Products Processing

Builder’s Paper and Board Mills

Coil Coating

Electric and Electronic Components Manufacturing

Feedlots

Fertilizer Manufacturing

Ink Formulating

Iron and Steel Manufacturing

If your facility employs or will be employing processes in any of the industrial categories or business activities listed below (regardless of whether they generate wastewater, waste sludge, or hazardous wastes), place a check beside the category of business activity (check all that apply).

A facility with processes inclusive in these business areas may be covered by Environmental Protection Agency’s (EPA) categorical pretreatment standards. These facilities are termed “categorical users”.

2. Is your business a categorical user?

Yes

3. Is your business a significant industrial user?

Yes

4. Appropriate Standard Industrial Code(s) (SIC):

I. Do you use, store, or discharge any acids, bases, or materials listed in Table I (attached)?

Yes

J. Does the operation of your processes or wastewater treatment facility result in a residual residue or sludge type waste?

Yes

K. Number Of Employees

Hrs/day

Days/wk

Shifts/day

Mos/yr

Size of the facility

L. What types of waste(s) do you discharge to the sanitary sewer?

Domestic (sanitary) Waste

Non-Contact Cooling Water

Contact Cooling Water

Boiler Blowdown

Scrubber Waters

Photo processing / X-ray developing waters

Grease Trap / Grease Interceptor

Process Water

Arsenic discharge, backwash water from drinking water system

Other

If other:

**All non-domestic users shall have a sampling manhole outside that provides access to the discharge from their facility.

***All Users with a discharge other than domestic sanitary waste (process waste water) shall have a sampling manhole outside that provides access to the waste stream without sanitary waste contribution.

If your answer to Section I. Question L. was only “1. Domestic waste,” sign and return this portion of the publication.

II. PROCESS AND PRODUCTS

A. Provide a complete list of products used or stored on the site, which appear on Table I (Consolidated Critical Materials List and Priority Pollutants List). If you use the trade name of proprietary chemicals that do not list contents on the package, indicate the trade names and manufacturer(s) at this time. You must write the manufacturer to request an OSHA Form 20 for each such substance, and provide POTW with the necessary information when available; i.e., use numbers, NOT chemical name, Table I:

B. Describe each process (include flow diagrams and plumbing schematics under Part IV):

C. Is any of the enclosed information considered to be confidential?

Yes

If yes, explain what and why. (All requests for confidentiality will be processed according to 40 CFR, Part 2):

D. Water Supply

Municipal

Well

Other

Other (Explain)

E. Municipal Consumption Used (ft3, gals per time unit)

Well Consumption Used (ft3, gals per time unit)

Total Consumption Used (ft3, gals per time unit)

F. Does your facility have a Spill Prevention Control and Counter Measures Program (SPCC) (40 CFR 112) or Pollution Incident Prevention Plan (PIPP) (MDNR Rule 5)?

Yes

III. PROCESS WASTEWATER

A. Identify outfall

Surface waters

Septic tank-tile field

Surface of ground

Municipal sanitary sewer

Storm sewer

Other

Other (Explain)

B. Volumes of discharge: Average Daily Flow (Gallons per day)

Volumes of discharge: Maximum Daily Flow (Gallons per day)

Flow is

Measured

Estimated

C. Type of wastewater discharged to the POTW:

Average Flow Rate: Process (GPD)

Maximum Flow Rate: Process (GPD)

Average Flow Rate: Domestic Waste (GPD)

Maximum Flow Rate: Domestic Waste (GPD)

Average Flow Rate: Non-Contact Cooling Water (GPD)

Maximum Flow Rate: Non-Contact Cooling Water (GPD)

Average Flow Rate: Boiler Blow Down (GPD)

Maximum Flow Rate: Boiler Blow Down (GPD)

Average Flow Rate: Total Flow Rate (GPD)

Maximum Flow Rate: Total Flow Rate (GPD)

D. Characteristics of wastewater discharge: All current nondomestic users are required to submit monitoring data on all pollutants that are expected to be present in the wastewater discharge. Use Table I – Critical Materials provided at the end of this application as a guide. Attach all laboratory data and submit with this application. If a new discharge and no data is available, provide an estimate of the expected concentrations for each pollutant.

File

Max. file size: 256 MB.

E. Are drains (roof, parking lot, etc.) discharging into the sanitary sewer?

Yes

If yes, estimate area drained: (sq. ft.)

IV. BUILDING AND PLUMBING LAYOUT, FLOW DIAGRAMS

A. Plumbing Layout: On a separate sheet, draw to scale the building and plumbing layout of your facility (or provide blueprint showing same). Identify the location of sewer lines, wastewater process connections, water meters, storm drains, and any sampling points. The proposed sampling point for evaluating wastewater compliance shall be clearly identified on this submittal. Identify street locations, and N ↑ on all drawings.

B. Pretreatment System: On a separate sheet, sketch your pretreatment system(s), if applicable. Show the routing of process waters from each wastewater-generating process to the treatment system what will address it. For example: high-pH rinses to pH-adjust, heavy metals wastestream to precipitation system, or kitchen wastes to a grease interceptor. Describe treatment chemistry used. Show the flow of treated wastes from the treatment system to the sanitary sewer. Indicate all monitoring equipment, pH recorders, flow meters, ORP meters, samples points, etc.

C. Block Flow Diagram: On a separate sheet, draw a simple blow diagram showing the flow of water, materials, and chemicals from start to final discharge point for each activity that generates wastewater. Identify all unit processes (blocks) and number these to correspond to numbers identifying processes on the building and plumbing layout.

File

Max. file size: 256 MB.

V. PRETREATMENT

A. Check the pretreatment methods used in your facility.

Clarifier or Interceptor

pH Adjustment

Ion Exchange

Grease or Oil Separation

Electrolytic Recovery

Wastestream Segregation (Including solvents)

Biological Treatment

Air Stripper/Scrubber

Chemical Precipitation

Cyanide Destruction

Chromium Reduction

Ozonation

Filtration

Silver Recovery

Other

Indicate rated flow for each pretreatment method checked, and label the diagram accordingly.

B. Describe each pretreatment system checked above. ( e.g. design capacity, physical size, loading rate, etc.). If no pretreatment exists, please explain. (Please attach additional sheets if necessary.)

Explain how compliance is verified at each sample point. (e.g. In-house testing, certified outside lab, etc.):

C. Number of batches discharged per year / month / week / day

Average volume per batch: (Gallons)

Other comments on batch treatment, including material treated and treatment technology:

VI. SAMPLING AND MONITORING

A. After pretreatment (if used), can wastewater streams be sampled prior to mixing with other waste streams?

Yes

N/A

If "NO" please explain:

All significant industrial users must provide ACT with an adequate monitoring point for sample collection purposes. The monitoring point must provide ACT staff the ability to collect samples representative of your facility’s discharge. Provide a written physical description (manhole, lift station, stilling well, etc.) of the proposed sampling/monitoring location including at least two (2) distances with direction from fixed objects (walls, equipment, fences, etc.) where samples will be collected from.

B. Describe the wastewater discharge monitoring practices for your facility. Include the type of analytical tests and/or methods to be used, the frequency of testing, and the name of the person(s) who will perform the tests. Attach analytical data if available. Enclose a copy of any logs, check lists, forms, etc., which are maintained.

VII. FLOW MEASUREMENT

All permittees must collect flow proportioned composite samples unless it is demonstrated that time proportioned composite samples are representative of your facility’s discharge. A composite sample is defined by ACT as a sample that is collected over time, formed either by continuous sampling or by mixing discrete samples. The sample may be composited either as a time or flow proportional composite sample. A time proportional composite sample is composed of discrete sample aliquots collected in one container at constant time intervals providing representative samples irrespective of stream flow. A flow proportional composite sample is collected either as a constant sample volume at time intervals proportional to stream flow, or collected by increasing the volume of each aliquot as the flow increases while maintaining a constant time interval between the aliquots. Your facility must submit the requirements of item A, B, or C with the completed application.

A. Information on your facility’s discharge that demonstrates time proportioned composite samples are representative of your facility’s discharge.

The submittal must indicate on which of the following bases you are requesting an exemption from the flow proportioned composite sampling requirement:

The wastewater discharge flow rate is consistent - facility must provide discharge information to substantiate claim.
The wastewater is discharged on a batch basis and is homogeneously mixed prior to discharge – facility must thoroughly explain batch discharge and mixing process.
The wastewater flow rate although variable throughout a day, contains a consistent pollutant concentration. Information must be submitted to substantiate claim.
Other conditions that generate a time proportioned composite sample representative of your facility’s discharge.

B. A written action plan for implementing flow proportioned composite sampling.

This requires the installation of a flow-metering device at the established compliance point. The flow meter must be equipped with an analog output for connecting a 4 – 20mA sampler interface module.

Type of flow classification – open or closed channel: Open channel is defined as a channel where liquid flows with a free surface. Closed channel is defined as completely filled pressure conduit.
Description of proposed flow measurement technology: Description shall include the type of flow measurement device that is or will be installed, i.e. magnetic flow meter, venture flow meter, parshall flume, etc.
Specification of the measuring range and accuracy of flow measurement technology.
Manufacturer’s suggested calibration frequency. Please be advised that all facilities implementing flow proportioned composite sampling will be required to have their flow measurement device calibrated per manufacturer’s specifications.
Sampling Requirement - the transmitter for the flow measurement device must include a 6-pin military connector that reaches an appropriate distance for locating an automatic sampler. Indicate which of the following signal specifications your transmitter will utilize (please be advised that not all flow meters meet these specifications):
- Analog Signal: 4-20 mA. Facility must provide ACT with a sampler interface module that converts analog signal to pulse.
- Pulse Signal: requires a 25 millisecond or greater isolated contact closure with 5-15 VDC pulse.

C. Current ACT significant industrial users with approved flow proportional composite sampling plans shall provide the following information:

1. Type of flow classification (open or closed channel) - Open channel is defined as a channel where liquid flows with a free surface. Closed channel is defined as completely filled pressure conduit:

2. Type of flow measurement technology installed (magnetic flow meter, venture flow meter, parshall flume, etc.)

3. Specification of the measuring range and accuracy of flow measurement technology:

4. Manufacturer’s suggested calibration frequency:

5. Date of last calibration:

6. Calibration was performed by:

7. Flow meter output (volume per pulse):

COMPLETE THIS SECTION FOR EACH TYPE OF WASTE NOT DISCHARGED TO THE SANITARY OR STORM SEWERS. USE A SEPARATE FORM FOR EACH TYPE OF WASTE (e.g. Spent Silver Bearing Solutions, Mercury Wastes, Solvents, Medical Wastes, etc.).

Do not include wastes sent to sanitary landfill such as trash and garbage.

VIII. NON-DISCHARGED WASTE STREAM(S)

A. Identify the waste (e.g. spent chemical, treatment sludge, medical waste, etc.) and the process that generates the waste:

B. Physical state of the waste (liquid, sludge, slurry, etc.):

C. Brief characterization of waste (list hazardous ingredients and attach supporting MSDS or lab analysis):

D. Rate of waste generation in terms of quantity per day, week, month or quarter:

ON-SITE STORAGE

Method of Storage:

Typical Volume Stored:

Typical Length of Time in Storage:

Is Storage Site Secondarily Contained?

Yes

Are there provisions for Surface Drainage Collection?

Yes

(If you answered “yes” to either question above, please describe provisions for secondary containment and/or surface drainage collection.)

TRANSPORTATION

Name of Waste Hauler:

EPA No.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Method of Disposal (e.g. recycled, land disposal, incineration, etc.):

DISPOSAL

Name:

EPA No.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Method of Disposal (e.g. recycled, land disposal, incineration, etc.):

IX. SLUG DISCHARGE MANAGEMENT PLAN

All permittees are required to develop and submit a current Slug Discharge Management Plan to ACT. The Slug Discharge Management Plan may part of an integrated plan provided it contains all the minimum requirements of 40 CFR 403.8(f)(2)(vi) 1-4. The submitted plan must include ACT and the Michigan Department of Environmental Quality’s (MDEQ) Pollution Emergency Alerting System (PEAS) in the notification process.

The Slug Discharge Management Plan can be developed in either of two ways:

A. Develop a Slug Discharge Management Plan Control Plan that contains at minimum all the requirements of 40 CFR 403.8(f)(2)(vi) 1-4

B. Develop an integrated plan that includes at minimum all the requirements of a Slug Discharge Management Plan set forth in 40 CFR 403.8(f)(2)(vi) 1-4

ACT additionally requires that the submitted plan be re-submitted for review every four years. Significant industrial users must notify the Township immediately if any changes occur at your facility that affect the Slug Discharge Management Plan or spill/slug potential.

If your facility does not have a Slug Discharge Management Plan or an integrated plan meeting the minimum requirements of 40 CFR 403.8(f)(2)(vi) 1-4, one will be required to be submitted to the Township within 90 days of receiving an industrial user permit. ACT requires completion of the following section for applicants not submitting a plan meeting the requirements described above:

Describe your facility's procedures for assuring that concentrated or prohibited chemicals do not spill or leak into the wastewater. (e.g. segregation controls, hard plumbing, etc.) Provide extra sheets if necessary.

Do you maintain a spill log?

Yes

Please be advised notification of the POTW in the event of a spill, bypass or an upset is required by law. Your facility shall contact the ACT Utilities Director at 616.262.3517 in the event of a spill, bypass, or upset.

Describe your facility’s Employee Training Program for Chemical Handling:

Describe your facility’s Emergency Response Procedures in the event of a spill:

Describe your facility’s disposal procedures for miscellaneous floor water:

X. DISPOSAL PRACTICES

A. How do you dispose of spent chemicals?

Volume disposed of:

B. How do you dispose of spoilage?

C. How do you dispose of precipitates and/or sludges?

Volume disposed of:

D. Name of waste hauler:

License No.

E. Do you have pretreatment for your wastes:

Yes

If Yes is checked: Type, Size & Frequency of Operation

If Yes is checked, where and how are the wastes disposed of:

To sanitary sewer

Other

If other explain:

F. Do you have any air emission control equipment, which would discharge into the sewer system?

Yes

G. Are any of the materials listed in Table I discharged with the wastes?

Yes

List, by number, from Table I:

XII. MISCELLANEOUS

A. Describe any safety precautions to be observed by those visiting your site:

B. Contact Person:

Name

Title

Phone

Allendale Charter Township Non-Domestic Discharge Permit

Application For Non-Domestic Discharge Permit

View Glossary, Table 1 and Table 2

Download this form as a PDF

GENERAL INFORMATION

II. PROCESS AND PRODUCTS

III. PROCESS WASTEWATER

C. Type of wastewater discharged to the POTW:

IV. BUILDING AND PLUMBING LAYOUT, FLOW DIAGRAMS

V. PRETREATMENT

VI. SAMPLING AND MONITORING

VII. FLOW MEASUREMENT

A. Information on your facility’s discharge that demonstrates time proportioned composite samples are representative of your facility’s discharge.

B. A written action plan for implementing flow proportioned composite sampling.

C. Current ACT significant industrial users with approved flow proportional composite sampling plans shall provide the following information:

VIII. NON-DISCHARGED WASTE STREAM(S)

ON-SITE STORAGE

TRANSPORTATION

DISPOSAL

IX. SLUG DISCHARGE MANAGEMENT PLAN

X. DISPOSAL PRACTICES

XII. MISCELLANEOUS

B. Contact Person:

Contact Us

Township Offices