City of Largo Environmental Services Department Environmental Control Program th Avenue North Clearwater, FL Phone: (727)

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Bertina Bruce
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1 POCTS # (To be assigned by City of Largo Environmental Control.) City of Largo Environmental Services Department Environmental Control Program th Avenue rth Clearwater, FL Phone: (727) PRIVATELY OWNED COLLECTION / TRANSMISSION SYSTEM OPERATING PERMIT APPLICATION Section I - GENERAL INFORMATION (Please Print or Type) System Name: Company / Facility Name: System Address: (Physical Location of Collection / Transmission System) City: State: Zip Code: System Contact: System Contact Phone: address: 24 Hr. Emergency Contact: Emergency Contact Phone: Section II - PERMITTEE INFORMATION: Property Owner: Property Tax Folio Number: (As it appears in County Tax Records) Owner Address: City: State: Zip Code: Owner Contact: Owner Phone: address: Page 1 of 6

OPERATING PERMIT APPLICATION Section I - GENERAL INFORMATION (Please Print or Type) System Name: Company / Facility Name: System Address: (Physical Location of Collection / Transmission System)

2 Section III - COLLECTION SYSTEM INFORMATION: Year in which the original Privately-owned Collection/Transmission System (POCTS) was built: Year in which the last improvement / addition to the POCTS was performed: _ Are there any stormwater discharges into the POCTS? Do not know Has the sanitary sewer within the property / facility been evaluated for future rehabilitation? (if yes, provide schedule and scope of work) Attach a copy of as-build drawings depicting all pump stations, sewer pipes, force mains, gravity sewer lines, sewer service areas, sewer subsystems, and / or manholes within the Privately-owned collection/transmission system. Section III a. - GRAVITY COLLECTION SYSTEM: Number of individual service connections to collection system: Number of sanitary sewer manholes within collection system: (Box 1) Total length of gravity sanitary sewer lines in feet and type of material: <4 inch: Type: <4 inch: Type: <4 inch: Type: 4 inch: Type: 4 inch: Type: 4 inch: Type: 6 inch: Type: 6 inch: Type: 6 inch: Type: 8 inch: Type: 8 inch: Type: 8 inch: Type: 10 inch: Type: 10 inch: Type: 10 inch: Type: 12 inch: Type: 12 inch: Type: 12 inch: Type: 16 inch: Type: 16 inch: Type: 16 inch: Type: inch: Type: inch: Type: inch: Type: Types PVC: PVC VCP: Vitrified Clay Pipe CIP: Cast Iron Pipe OTH: Other DIP: Ductile Iron Pipe Section III b. - TRANSMISSION SYSTEM PUMP STATIONS AND FORCE MAINS: Number of pump stations within the collection system: (Box 2) Station # 1: Pump Size (Inches) Capacity (GPM) Station # 2: Pump Size (Inches) Capacity (GPM) Station # 3: Pump Size (Inches) Capacity (GPM) Station # 4: Pump Size (Inches) Capacity (GPM) Station # 5: Pump Size (Inches) Capacity (GPM) Page 2 of 6

(if yes, provide schedule and scope of work) Attach a copy of as-build drawings depicting all pump stations, sewer pipes, force mains, gravity sewer lines, sewer service areas, sewer subsystems, and

3 Section III c. - TOTAL LENGTH OF FORCE MAIN SANITARY SEWER LINES: (FEET) <2 inch: 2 inch: 3 inch: 4 inch: 6 inch: 8 inch: Other: Section IV OPERATION AND MAINTENANCE: Is there an Operations and Maintenance (O & M) manual for this system? (If yes, please attach a copy of the manual and answer MAN-1 through MAN-5) (If no, please complete OM-1 throughom-5) MAN-1 Does the manual include preventative maintenance procedures? MAN-2 Does the manual include spill containment and control procedures? MAN-3 Does the manual include an Emergency Response Plan? MAN-4 Does the manual include a line jet cleaning program? MAN-5 Does the manual include a sanitary sewer overflow remediation plan? OM-1 Describe routine maintenance performed on the collection and/or pump stations(s): As a minimum, use the City of Largo's monthly maintenance log for private manholes and/or private lift station. Page 3 of 6

4 OM-2 Describe spill containment and control procedures: As a minimum, stop using water for the property. OM-3 Describe emergency responses to be taken during system failures: As a minimum, provide name and number of Maintenance Personnel or Plumber. OM-4 Describe any line jet cleaning activities for the system: Jet cleaning of sanitary sewer lines is to be conducted on a as needed basis when ever accumulated debris is obstructing the normal flow pattern of the sanitary sewer system. OM-5 Describe overflows stabilization and remediation procedures: As a minimum: Call maintenance or plumber. Call City of Largo (727) Small spill (less than 5 gallons) - hose down, apply lime to contaminated area. Large spill - call vac truck, apply lime to contaminated area. Call Department of Environmental Protection ( Ext-335. List any additional procedures that will be performed: Page 4 of 6

OM-4 Describe any line jet cleaning activities for the system: Jet cleaning of sanitary sewer lines is to be conducted on a as needed basis when ever accumulated debris is obstructing the normal flow

5 Section V Inflow and Infiltration (I & I) Evaluation / Rehabilitative Work History Describe all inflow and infiltration evaluations and/or rehabilitative work performed between January 1, 1997 and the date of this application. Include any substantial system upgrades and the dates work was performed. Page 5 of 6

rehabilitative work performed between January 1, 1997 and the date of this

6 Section VI PERMIT FEE DETERMINATION Permit fees are established to offset the administrative cost of implementing and maintaining the Privately-owned Collection and Transmission Systems Ordinance, Chapter 23, Article IV of the City Code. The initial permit fee shall be paid with the submittal of this Privately Owned Collection / Transmission System Operating Permit Application. For those Privately Owned Collection and Transmission System located within the City s Sanitary Sewer District but outside the City limits, an additional 25% surcharge shall be assessed. The annual permit fee is based on the fee schedule established in Section , D. of the Ordinance. If the shaded Box 1 on page # 2 is greater than one (1), enter in Box 3 to the right. (Box 3) If the shaded Box 2 on page # 2 one (1) or greater, enter in Box 4 to the right. (Box 4) Add Box 3 to Box 4 and enter total amount in Box 5. If the Privately Owned Collection / Transmission System is located outside the City limits, multiply Box 5 times Enter the sum in Box 6. Add Box 5 to Box 6 and enter total amount in Box 7. This is the annual Privately owned Collection / Transmission System Operating Permit Fee. (Box 5) (Box 6) (Box 7) Section VII - Authorized Signature I certify under penalty of law that this document and all attachments were prepared under my direction or supervision and 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. Name Title ( ) Signature Date Phone Page 6 of 6

For those Privately Owned Collection and Transmission System located within the City s Sanitary Sewer District but outside the City limits, an additional 25% surcharge shall be assessed.

Sanitary Sewer Overflow Report Form

Preliminary report Final report Revised final report Sanitary Sewer Overflow Report Form Sanitary Sewer Overflow Sequential Tracking Number: Reported to: Sent Regional Board a fax Left Regional Board a