FORM A: APPLICANT QUESTIONNAIRE Name Of Company Company Contact Name Company Contact E-mail Phone Number FORM A: APPLICANT QUESTIONNAIRE 1. Reason for Submittal - Circle A ­ New Permit, B ­ Permit Revision, C ­ Permit Addendum, or D ­ Permit Renewal and complete the corresponding questions. A. New Permit (for new companies and for changes in ownership) Type of business Is the facility: New or Existing (please check) If existing, previous company name Type of business Industrial Wastewater Discharge Permit No. Provide a description of all manufacturing processes and wastewater producing operations in an attachment. Are any changes being made to the facility's existing wastewater pretreatment/conveyance systems? Yes No If yes, briefly explain these modifications in attachments. Is there more than one company discharging industrial wastewater at your facility? Yes No If yes, provide for each company its name, a separate address and a description of its operations. If feasible, each company must apply for a separate permit and must have its own incoming water meter and a separate industrial wastewater sampling point. If your facility will involve a new connection to the public sewer, please check the point of connection: Local city sewer, Sanitation Districts' Trunk sewer. If you are relocating, and had a previous Industrial Wastewater Discharge Permit, give your previous address , and permit number . If you have received a temporary permit, give permit number . All submittals for new permits must include a permit application, plans (if changes have occurred) and pertinent supporting information. B. Revision of Existing Permit (for a 25 percent or more change in wastewater quantity/quality) Permit number . Has your wastewater quantity and/or quality changed over 25 percent? Yes No If yes, documentation addressing the magnitude and reason(s) for the change must be submitted. If no, a revision is not required at this time. Have there been any changes in production processes, wastewater pretreatment systems or sewerage plumbing? Yes No If yes, submit plans and describe these changes in attachments. All submittals for a revised permit must include a permit application, plans (if changes have occurred) and supporting information. C. Addendum to Permit (for modifications to the wastewater conveyance/pretreatment system) Permit Number . Attach a brief summary of the existing conditions and the proposed changes. All submittals for a permit addendum must include plans and supporting information. Applicant must also answer the questions on the back of this form (2. Supporting Information Required). American LegalNet, Inc. www.FormsWorkFlow.com D. Permit Renewal (for permits with expiration dates) Permit Number . Have there been any changes in production processes, wastewater pretreatment systems or sewerage plumbing? Yes No If yes, submit plans and describe these changes in attachments. All submittals for a permit renewal must include a permit application, plans (if changes have occurred) and supporting information. 1. Supporting Information Required All submittals must include the following forms, which are included in Appendix 6.1: Form A - Applicant Questionnaire Form B - Calculation of Industrial Wastewater Discharge Flow Rate Form C - Tank Schedule and Spill Containment Calculations Form D - Check List Furthermore, your company must answer the questions below to determine the additional supporting information that must be provided: A. Waste Minimization (refer to Sections 2.4 and 3.3 E) Please describe below or in an attachment all of your company's existing/proposed pollution prevention measures (e.g., reuse, product reformulation, process changes, housekeeping measures, etc.): Has your company previously submitted a waste minimization plan to the Districts? Yes No If no, please read Sections 2.4 and 3.3E and submit the appropriate plan (if applicable). Your company is encouraged to obtain information on source reduction measures and options for your industrial processes by calling the Districts' Industrial Waste Section at (562) 908-4288, ext. 2900. B. Wastewater Quality (refer to Sections 3.3G and H) Please provide the results of at least two 24-hour composite analyses attesting to concentrations of chemical oxygen demand, suspended solids and any priority or regulated pollutants that may be found in your wastewater. Your company must also provide material safety data sheets of all chemicals used in the facility that may directly or indirectly contaminate your wastewater. C. New Equipment (refer to Sections 3.3 F, J and K) Is your company installing new pretreatment, monitoring, conveyance or industrial equipment that may have an impact on the quality or quantity of your wastewater? Yes No If yes, please provide catalog cuts of all units and important details such as: number of units, sizes, hours of operation, pump rating curves, operating parameters, etc. D. Baseline Monitoring Report (refer to Sections 2.1 and 3.3 I) Does your company currently fall under one of EPA's categories? Yes No If yes, your company must submit a Baseline Monitoring Report, unless it was submitted one in the past and there have been no changes in operations that may change your categorical standards. E. Rainwater Management (refer to Section 3.2) Are there any outdoor drains, trenches or sumps at your facility that are connected to the sewerage system? Yes No If yes, your company must submit plans and information that describe the existing means to divert rainwater from the sewerage system or a proposal to comply with the Districts' rainwater guidelines. Please be informed that new automatic rainwater diversion systems will not be approved unless the applicant proves that this is the only feasible alternative. American LegalNet, Inc. www.FormsWorkFlow.com