Halifax Water Pollution Prevention Program Detailed Discharger Information Report (Form 2)

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Amice Mason
7 years ago
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To complete this form online you will need to use Adobe Acrobat Reader. Adobe Acrobat Reader is available for FREE and can be downloaded from the following web site: http://www.adobe.

1 To complete this form online you will need to use Adobe Acrobat Reader. Adobe Acrobat Reader is available for FREE and can be downloaded from the following web site: The completion of this form by all dischargers to wastewater facilities is required under Schedule of Rules and Regulations for Wastewater Services if requested by the Commission. Company Name, Corporation: Owner: Mailing Address: Phone: Address: Fax: What are your principal products produced or services provided: Provide a brief description of your manufacturing or service activities:

2 Standard Industrial or Canadian Codes (SIC) of those products produced: Halifax Water Pollution Prevention Program Indicate if these are [ ] SICs, or Canadian [ ] SICs. Number of employees: Plant: Number of shifts per day: Office: Number of shifts per week: Please indicate if major processes are: Batch Continuous Both Seasonal Variation If yes indicated, briefly describe your seasonal production cycle:

3 List all sources of water supply: Municipal water Private well water Hauled water Other sources (Describe) Type of wastewater discharged: (please check all that apply) Description: Domestic Wastewater n-contact cooling water Contact cooling water Process water Other Wastewater is discharged to: (please check all that apply) Location Estimated Volume Wastewater #1 Wastewater #2 Storm Sewer #1 Storm Sewer #2 Surface water, pond, creek, river, etc. Storage Tank Ground water or well Liquid waste hauler - please indicate company used and disposal site if known.

4 Physical Layout Provide sketch of property (to scale or approximate) showing buildings, pretreatment facility or interceptors, property boundaries, effluent lines, and connections to wastewater, combined and storm sewers. Layout may be attached as separate document - leave note to indicate submission with this form. Flow diagram of the site flows/processes is also required. Provide existing sampling data on the chemical composition and concentrations within the discharges listed above. Pre-treatment devices or processes used for treating wastewater or sludges before discharge to the sewer system. ( Please check as many as is appropriate): [ Air flotation [ Centrifuge [ Chemical Precipitation ] Chlorination Cyclone ] Filtration ] Flow Equalization ] Grease or Oil Separation, ] Rainwater Diversion or Storage ] Grease Interceptor Grit Removal [ Ion Exchange ] Neutralization, ph correction ] Ozonation ] Reverse Osmosis ] Screening ] Sedimentation ] Septic Tank ] Solvent Separation Spill Protection ] Sump ] Biological Treatment type: Other Chemical Treatment Other Treatment type: Pre-treatment Provided

5 Describe in detail the treatment process for your waste streams including flows, pump run times and size of pumps. Include any relevant operational data Are solids generated from the pre-treatment process: If yes, please describe the treatment and disposal method for sludge removal, Do you recover any chemicals from your wastewater: If yes, please explain

6 List pollutants or chemical that have the potential to enter either wastewater or storm sewers due to accidental spills, machinery malfunctions or process upset: Name: Title: Address: Phone: Date of Completion If you have any questions regarding this form please contact To submit this form online you will need to have an program installed on your computer. If the Submit button is not working, please save the form to your computer hard drive, attach it in an and send to:

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