Environmental Services Department

Environmental Survey

 

Completion of this survey is mandatory.  Federal regulations [40 CFR 403.8(f)(2)(i)] require the City of Carrollton to identify and locate all possible industrial users that might be subject to the federally-mandated Industrial Pretreatment Program. In addition, §171.19 (A) of the City of Carrollton Code of Ordinances requires any person to comply with the submission of a completed environmental survey, when necessary to determine the industrial user status of that person. Failure to comply with this ordinance may result in a fine of not more than $2,000.

Note: Each item must be answered. If not applicable to your business, please indicate N/A.

Section A: General Information

1. Company Name:

 *

1. Company Name:

2. Parent Company Name:

2. Parent Company Name:

3. Facility Address:

 *

3. Facility Address:

4. Telephone Numbers:

 *

4. Telephone Numbers:

Telephone No:ext.

Emergency No:ext.

5. Other:

5. Other:

Fax No:ext.

Email Address

6. Date Operations Started at Present Site:

 *

6. Date Operations Started at Present Site:

7. Contact Persons:

 *

7. Contact Persons:

Name #1:	Title:	Email:
Name #2:	Title:	Email:

8. SIC Codes:

 *

8. SIC Codes:

Primary:

Secondary:

Other:

---

9. Average total water usage (from past 12 months water bill):

 *

gpd

10. Average water usage for manufacturing process:

 *

gpd

11. Type of products or services:

 *

11. Type of products or services:

12. Describe stepwise basic manufacturing or industrial process (starting from raw materials to end product):

 *

12. Describe stepwise basic manufacturing or industrial process (starting from raw materials to end product):

13. List existing environmental permits (stormwater, air, etc.):

13. List existing environmental permits (stormwater, air, etc.):

Type of Permit/Government Agency:	Permit Number:
Type of Permit/Government Agency:	Permit Number:
Type of Permit/Government Agency:	Permit Number:

14. Work schedule information:

 *

14. Work schedule information:

Number of Employees:

Days of Operation:

No. of Shifts:

Hours of Shifts:

Section B: Water Supply

1. Water Source:

 *

1. Water Source:

Private Well	Surface Water
Municipal Utility (Specify City): If other, type text here.	Other (Specify): If other, type text here.

Section C: Sewer Information

1. For an existing business:

Is the building presently connected to the public sanitary sewer system?

 *

1. For an existing business: Is the building presently connected to the public sanitary sewer system?

Yes

No

2. For a new business:

a. Will you be occupying an existing vacant building?

2. For a new business: a. Will you be occupying an existing vacant building?

Yes

No

b. Have you applied for a building permit if a new facility will be constructed?

b. Have you applied for a building permit if a new facility will be constructed?

Yes

No

c. Will you be connected to the public sanitary sewer system?

c. Will you be connected to the public sanitary sewer system?

Yes

No

Section D: Wastewater Discharge Information

1. Does (or will) this facility discharge any wastewater other than domestic wastewater from the restrooms to the city sewer?

 *

1. Does (or will) this facility discharge any wastewater other than domestic wastewater from the restrooms to the city sewer?

Yes

No

2. Indicate the types of wastes (other than sanitary) that your facility discharges (or will discharge) to the sewer.

2. Indicate the types of wastes (other than sanitary) that your facility discharges (or will discharge) to the sewer.

Cooling water	Boiler blow down
Chemicals	Oils and/or grease
Pesticides	Solvents
Equipment/vehicle/tanker cleaning	Laundry wastes
Rinse waters	Food processing
Photo finishing wastes	Medical wastes
Acids or bases	Radioactive wastes
Polychlorinated biphenyls	Stripping compounds
Equipment cooling	Other: If other, type text here.

Will SDS sheets for hazardous chemicals be attached? Send documents to  Pretreatment_Program@cityofcarrollton.com

 *

Will SDS sheets for hazardous chemicals be attached? Send documents to Pretreatment_Program@cityofcarrollton.com

Yes

No

3. Are there any on-site wastewater treatment/pretreatment facilities?

 *

3. Are there any on-site wastewater treatment/pretreatment facilities?

Yes If other, type text here.

No

Section E: Pollution Prevention Information

1. Is there a solvent/toxic organic management plan (TOMP)?

 *

1. Is there a solvent/toxic organic management plan (TOMP)?

Yes

No

2. Is there a source reduction/waste minimization or pollution prevention plan?

 *

2. Is there a source reduction/waste minimization or pollution prevention plan?

Yes

No

3. Is there a spill control plan?

 *

3. Is there a spill control plan?

Yes

No

4. Is there an emergency/contingency plan?

 *

4. Is there an emergency/contingency plan?

Yes

No

5. Has a Tier II report been completed?

 *

5. Has a Tier II report been completed?

Yes

No

6. Chemical Storage

a. Are there bulk chemicals on site (55 gallon drums, 300 gallon totes, etc.)?

 *

6. Chemical Storage a. Are there bulk chemicals on site (55 gallon drums, 300 gallon totes, etc.)?

Yes

No

b. Are there extremely hazardous substances (EHS) on site?

 *

b. Are there extremely hazardous substances (EHS) on site?

Yes

No

c. Are there storage tanks on site?

 *

c. Are there storage tanks on site?

Yes

No

 If yes, then

If yes, then

Capacity:

TCEQ Registration #

Number of monitoring wells:

And does storage tank have:

And does storage tank have:

Overfill protection

Corrosion protection

Secondary vapor recovery

If removed:

Removal Date:

Remediation?

 *

Remediation?

Yes

No

7. Waste Disposal

a. Hazardous Waste

1. What hazardous wastes are generated?

 *

1. What hazardous wastes are generated?

2. Hazardous waste category:

 *

2. Hazardous waste category:

Very Small Quantity Generator (0-220 lbs hazardous waste/month)

Small Quantity Generator (220-2,200 lbs hazardous waste/month)

Large Quantity Generator (2,200+ lbs hazardous waste/month)

3. Is hazardous waste sent to sanitary sewer?

 *

3. Is hazardous waste sent to sanitary sewer?

Yes

No

4. Types of waste storage

 *

4. Types of waste storage

5. Storage location:

 *

5. Storage location:

6. Are manifests kept on site?

 *

6. Are manifests kept on site?

Yes

No

b. Liquid Waste (grease trap/interceptor, oil/water separator, grit/sand trap)

 *

b. Liquid Waste (grease trap/interceptor, oil/water separator, grit/sand trap)

1. Trap Types and Capacities

2. Frequency of clean out

3. Transporter name:

4. Are trip tickets kept on site?

c. Other Industrial Waste Generated

 *

c. Other Industrial Waste Generated

1. What other industrial wastes are generated?

2. Means of disposal?

d. Stormwater Permit Status

1. Does the company have a stormwater permit from TCEQ?

 *

1. Does the company have a stormwater permit from TCEQ?

Yes

No

2. Does the company have a no exposure certification from TCEQ?

 *

2. Does the company have a no exposure certification from TCEQ?

Yes

No

3. Is there a stormwater pollution prevention plan?

 *

3. Is there a stormwater pollution prevention plan?

Yes

No

4. Is there equipment/vehicle/tank/tanker washing on site?

 *

4. Is there equipment/vehicle/tank/tanker washing on site?

Yes

No

5. Are there uncovered compactors/dumpsters on site?

 *

5. Are there uncovered compactors/dumpsters on site?

Yes

No

6. Are there drums, chemicals, or other industrial activities outside?

 *

6. Are there drums, chemicals, or other industrial activities outside?

Yes

No

F: Site Map

Please provide a sketch locating the various operations and chemical storage inside the facility and outside storage areas, monitoring wells, storm water outfalls, nearby water bodies and notes. Send any documents to Pretreatment_Program@cityofcarrollton.com

G: Signatory

Certification Statement to be Completed by Industry

I have personally examined and am familiar with the information submitted in this document and attachments.  Based upon my inquiry of those individuals responsible for obtaining the information reported herein, I believe that the submitted information is true, accurate and complete.

 

 *

Printed Name

Title

Date

This section is to be completed by the City Inspector

Findings:

 

 

 

 

 

 

 

Name/Signature:__________________________________________         Date:____________________________________

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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