1. Facility Name
2. Premise Address
3. Mailing Address
4. Name and title of contact person
5. Phone Fax
6. E-mail

1. Type of Business
2. North American Industry Classification System (NAICS) codes(s)
3. Provide a detailed description of the commercial/industrial processes that take place at this facility (attach additional sheets if necessary through the e-mail link below)
4. Facility Discharges to (check all that are applicable) City sewer
5. South St. Joseph Industrial Sewer District (SSJISD) sewer
6. Septic system
7. Other (describe)

NOTE: If the facility discharges to the city’s wastewater treatment plant (either directly via city sewers or via SSJISD or other sewers), please complete the rest of this questionnaire. Otherwise, skip to Section 4.

1. Beginning date of Operations at this location (mm/dd/yyyy)
2. What are the total hours of operation in a day? 1-8 9-16 17-23
3. Number of shifts in a day 1 2 3
4. Total number of employees 0-15 16-50 51-100 101-300 300+
5. Are any waste hauled off site? Yes No
6. If yes, please indicate the type of waste Acid/Alkalies Oil & Grease Radioactive Heavy Metal Solvents
7. Paint Pesticides Other (describe)

Indicate the type of environmental operating permits the facility currently has:

8. Hazardous waste Permitting Authority Permit #
9. Solid waste Permitting Authority Permit #
10. Air Permitting Authority Permit #
11. Stormwater Permitting Authority Permit #
12. NPDES Permitting Authority Permit #
13. Other Permit Permitting Authority Permit #
14. None

Indicate where water is used in the facility

15. Boiler feed water Non-contact cooling Irrigation
16. Shipped out with product Commercial/Industrial process Sanitary
17. Other None
18. Average wastewater discharge volume. If discharge is of a continuous nature, indicate volume in gallons per day. If discharge will be of a batch nature, indicate volume of each batch discharge in gallons and frequency (i.e. number of days, weeks, months, etc. between each batch discharge)
    
19. Does the facility currently treat wastewater prior to discharge? Yes No

To attach submitted documents for the following, see end of page.

20. Submit with the completed questionnaire a list of chemicals that are used or stored at this location.
    

Submit with the completed questionnaire a Material Safety Data Sheet for each chemical listed in the previous item.

Submit with the completed questionnaire, the anticipated concentrations for all chemicals or pollutants that are expected to be present in the wastewater discharged to the sewer. If the wastewater from this or a similar facility has been analyzed for pollutant concentrations, submit copies of lab reports or a summary of analytical results with the completed questionnaire. At a minimum, provide anticipated concentrations for the following pollutants:

5-day biochemical oxygen demand (BOD5) Total suspended solids (TSS) Fats, oils and grease (FOG) pH Cadmium Chromium

Copper Lead Nickel Silver Sulfide Zinc

Please submit with the completed questionnaire a diagram or utility plan (blueprint) of the facility showing the location and orientation of the facility with respect to nearby streets. This diagram should also show the location and routing of water lines, sewer lines, floor drains, sinks, toilets, grease traps, oil/water separators, wastewater treatment equipment, and chemical storage locations, etc.

Refer to Section 29-131(3) of the St. Joseph Code to determine which individual(s) qualify as an authorized representative for this facility.

1. 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.
2. Please type your name Title Date

(Please enter/spell your name as you would sign your signature)

To attach submitted documents, click on the following e-mail link to send an email with the attachments.
To: Water Protection