The survey must be completed and appropriately signed. This form must be signed by a corporate officer or manager per 40 CFR 403.12(1).
GENERAL INFORMATION Site Address
Representative Completing the Form Name
Contact in Case of Emergency Name
Property Owner Name
Will / Is the building connected to the public sewer system? Is Facility connected to the HBPW potable water system? If Yes, does facility have an approved backflow device? Location and size of all approved backflow devices: (Attach additional pages if necessary at the end of the survey) Describe in detail the type of business activity conducted at this site. Include primary products or services: Is this facility a categorical industry as defined by 40 CFR 403 through 40 CFR 71? Select the appropriate category below (hold down the CTRL key to select multiple lines) Aluminum Forming Battery Manufacturing Builders' Paper and Board Mills Carbon Black Manufacturing Coil Coating Copper Forming Electrical or Electronic Component Electroplating Feedlot Fertilizer Manufacturing Glass Manufacturing Grain Mill Ink Formulating Inorganic Chemical Manufacturing Iron and Steel Manufacturing Leather Tanning and Finishing Metal Finishing Metal Molding or Casting Nonferrous Metal Forming / Metal Powders Organic Chemicals, Plastics & Synthetic Fibers Manuf. Paint Formulating Paving or Roffing Materials (Tar & Asphalt) Pesticide Chemicals Petroleum Refining Pharmaceutical Menufacturing Porcelain Enameling Pulp, Paper, or Fiberboard Manufacturing Rubber Manfuacturing Soaps or Detergent Manufacturing Steam Electric Power Generating Timber Products Processing Will ou use EPA Toxics Release Inventory (TRI) chemicals in reportable quantities? Identify the above chemicals and quantities used (attach additional sheets if necessary): Will your site have an irrigation or drinking water well? Will your site have any underground injection control facilities (UIC's such as drywells, drill holes, or drainage pipe galleries)? Will you store chemicals at your facility in a volume greater than 5 gallons each? If yes, give description of contents, container size and type, storage location, frequency and method of container cleaning. Indicate if buried metal containers have cathodic protection. Has your company ever been issued a local, state, or federal environmental permit? If yes, list the permit(s): Does this facility use products that contain any of the following items listed below? Select all that are present. Product verification should be accomplished by product label and MSDS. (hold down the CTRL key to select multiple lines) Acetone Arsenic Barium Benzene Cadmium Chloroform Chromium Copper Cyanide Ethyl Benzene Lead Mercury Methylene Chloride NIckel Petroleum Based Oils Phenois / Phenolics Selenium Silver Toluene Xylene Zinc Waste Discharge (hold down the CTRL key to select multiple lines) Air Pollution Control Equipment Anodizing Beverage Bottling / Manufacturing Boil / Cooling Blowdown Chemical Etching or Milling Cooling Water, Contact Cooling Water, Non-Contact Domestic Waste Electroplating Equipment Manufacturing Fertilizer Application Service Grain Mill Food Processing Food Service Establishment Groundwater Treatment Laundry Medical / Dental Services Metal Coating (Chromating, Phosphating, etc.) Pesticide Application Service Photographic / Film Processing Plastic Processing Powder Coating Printed Circuit Board Manufacturing Printing and Publishing Process Water Slaughter/Meat Packing/Rendering Vehicle-Equipment Manufacturing/Repair Vehicle or Equipment Washdown Waste Recycling Water Treatment Wood Preserving Will you use fats, oils, grease (cooking or petroleum), or dairy products in your business? Will there be a garage disposal unit (food grinder) at your business? Will there be an inteceptor, separator, or other device installed to pretreat your wastewater prior to discharge? If Yes, select all that apply (hold down the CTRL key to select multiple lines) Amalgam Separator Amalgam Chairside Trap Grease Interceptor, Outside Capacity Grease Interceptor, Inside Capacity Hair Trap Oil / Water Seperator pH Neutralizer Silver Recovery System What is the method of Disposal of all materials collected via pretreatment process and pretreatment device maintenance? Will you generate hazardous waste as defined by the Missouri DNR and Federal regulations (RCRA)? Will you discharge any RCRA listed or characteristic hazardous wastes to the sanitary sewer? Do you have any accidental spill prevention document to prevent spills or chemicals or sludge discharges from entering the City's sanitary sewer or storm systems? If so, please attach at the end. Provide any additional comments or explanations here Please upload any additional documentation for sections above.
Drop files here or
Max. file size: 30 MB, Max. files: 6.
"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 gathered the information submitted. Based on my inquiry of the person of persons who manage the system, or those persons directly responsible for gathering the information. Based on my inquiry of the person or persons who manage the sytem, 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 there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations."
Printed Name (Required)
Signature locked. Reset to sign again