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Home My WebLink AboutTHE FLATS AT HANSEN FARM - FDP230004 - SUBMITTAL DOCUMENTS - ROUND 2 - OTHER WATER AND OR SANITATION DISTRICTS11/19/20141 South Fort Collins Sanitation District Industrial Pretreatment Business Questionnaire 5150 Snead Drive Fort Collins, Colorado 80525 (Office) 970-226-3104 (Fax) 970-226-0186 The South Fort Collins Sanitation District (the District) requires that all commercial and industrial businesses fill out the following Industrial Pretreatment Business Questionnaire. The information provided will be used to update the District’s Wastewater Pretreatment User Database and assist us in monitoring what types of waste are being discharged into the sanitary sewer system. IMPORTANT: Before submitting this questionnaire, please complete as thorough and as accurate as possible. All of the sections are important and should be completed to the best of your knowledge. Take extra care to ensure that all sections have been filled out properly and section IV. Certification of the form is carefully understood and signed. If you do not understand any of the sections contained in this questionnaire, please contact Dave Haughey for assistance at 970-226-3104, x110. I. GENERAL INFORMATION Business Name: ____________________________________________________________________ Individual Responsible for Operation: Individual Providing Information: Name: ___________________________________ Name: __________________________________ Title: ___________________________________ Title: ___________________________________ Phone: ___________________________________ Phone: __________________________________ Location Address: __________________________________________________________________ Subdivision Development: ____________________________________________________________ Lot Number: _______________________________ Block Number: ___________________________ Contact Address (if different from above): _______________________________________________ Phone: ____________________________________________________________________________ Fax Number: _______________________________________________________________________ Email Address: _____________________________________________________________________ Days of Operation: __________________________________________________________________ Hours of Operation: _________________________________________________________________ 970 568-5405 Project Engineer Benjamin Ruch Normal business hours Everyday ryans@affinitycre.com N/A Same as above 3665 John F Kennedy Pkwy Building 2, Suite 202, Fort Collins, CO 80525 N/ATracts D, E, and L Hansen Farm Not yet assigned (970)663-3150 Manager Ryan Schaefer Hansen MF, LLC DocuSign Envelope ID: 841533D9-ADB9-41B8-B07E-42D163C4D499 11/19/20142 Number of Employees: _______________________________________________________ Is this Business in a multi-use building (are there other Businesses in the same building)?  Yes  No If Yes, which unit(s) do you occupy? _____________________________________________________________________ Are you the owner of the property?  Yes  No If No, please provide the name and address of the owner. _____________________________________________________________________ If you lease the building to several different clients, please list the name of each client, suite and description of the activity or operation of each client. Client’s Name Address Activity / Operation __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Business official to be contacted about this survey: _____________________________ __________________ ________________ Name Title Phone # II. PRODUCT INFORMATION Give a brief description of the operations at this facility including primary products and services. (970)663-3150ManagerRyan Schaefer Clubhouse with pool to an apartment complex development 2 DocuSign Envelope ID: 841533D9-ADB9-41B8-B07E-42D163C4D499 11/19/20143 Check all activities that occur at your facility. Assembly Machining – Sheet Metal Shop Auto body, Shop, Vehicle Repair Painting / Finishing / Stripping Auto / Truck Wash Photography Battery Manufacturing Plant Wash Down Biotechnology Plastics/ Manufacturing/Molding/Forming Cement Manufacturing Pharmaceutical Manufacturing Chemical Manufacturing Photo Processing Copper / Aluminum Forming Plastics manufacturing / molding Dairy Products Porcelain Enameling Dry Cleaning / Laundries Printed Circuit Board Manufacturing Education/Vocation Printing/Publishing Electrical Component Assembly Pulp, Paper, Paperboard Manufacturing Electroplating Research Engraving/Coating Restaurant Feedlot Retail Trade Flammables/Explosives Rubber Manufacturing / Processing Food Processing Smelting Funeral Services Soap / Detergent Manufacturing Gas Station Steam/Power Generation Glass Manufacturer Sugar Manufacturing Government Textile Manufacturing Grain Mill Timber Products Laboratory Vehicle Repair Leather / Tanning/Finishing Warehouse Office Unit Wholesale Trade Manufacturing Wood Preserving / Finishing Medical Care Woodworking Shop Metal finishing (plating, anodizing, coating, etching X-ray Metal Modeling and Casting Other (Specify)___________________ III. WASTE GENERATION AND DISPOSAL INFORMATION No drains, roof downspouts, exterior foundation drains, sumps, area drains or other sources of surface runoff or groundwater shall be connected directly or indirectly to a Sanitary Sewer unless such connection is approved by the General Manager. Are There Any Floor Drains in the storage or use area(s)? Yes No DocuSign Envelope ID: 841533D9-ADB9-41B8-B07E-42D163C4D499 11/19/20144 Note: Floor drains are drainage fittings that sit flush with the floor. They’re used in basements, bathrooms, laundry and furnace rooms, garages, etc. Since floor drains are connected to the SFCSD sewer system, the District needs to know what potentially goes down the drain and where it is located. Where are the floor drains located? (You may include a separate drawing.) __________________________________________________________________________________ Identify which of the following discharge to the sanitary sewer: ⁭ Pool ⁭ Fountain ⁭ Loading dock drain ⁭ Sump pump(s) ⁭ Roof drain ⁭ Storm water ⁭ Outside drains What is the maximum water use at this facility? _________ gallons per ⁭ day ⁭ month ⁭ estimated ⁭ unknown Is there a grease trap or sand & oil interceptor? Yes No If yes, please list the capacity (gallons): ______________ Method of Wastewater Disposal (check one):  Municipal Sewer Septic Tank Type of Wastewater Discharge into Municipal Sewer (check one or both): ___ Domestic ___ Industrial List types and amounts of chemicals, fluids, and/or liquid waste used in gallons per day. Indicate the method of disposal for each by listing the letter that corresponds to the appropriate method. Attach additional sheets if necessary. If none are used, write NA in the space. Methods of waste disposal: a. Discharge to SFCSD sewer system.c. Placement with trash for collection. b. Discharge to SFCSD sewer system after pretreatment. d. On-site storage, treatment or disposal. e.Shipment off-site by outside hazardous waste hauler to waste management facility. 800 Floor Drains will be located in mechanical rooms and restrooms. DocuSign Envelope ID: 841533D9-ADB9-41B8-B07E-42D163C4D499 11/19/20145 Chemical, Fluid, Liquid Waste Amount (gal/day) Method of Disposal If an outside firm removes hazardous waste, state the name and address of all waste haulers and indicate the wastes picked up and the frequency. Firm’s Name and Address Waste picked up Frequency of pickup IV. FLOW PREVENTION Do you have a back flow prevention device on-site? Yes ____ No ____ If yes, when was the last time (mm/dd/yyyy) it was inspected? ____________________ V. CERTIFICATION The discharge of listed or characteristic RCRA hazardous waste, as set forth in 40CFR Part 261, into the South Fort Collins Sanitation District (the “District”) sanitary sewer system is strictly prohibited without prior notification to the District, and the completion and approval of a Hazardous Waste Notification form. Failure to comply with this regulation is a violation of Federal law contained in 40CFR 403.12(p) and will subject your business to enforcement actions by the USEPA. As a duly authorized representative of this business, I hereby certify under penalty of law that I have personally examined and am familiar with the information found in this questionnaire and all attachments submitted herein. To the best of my knowledge the information is complete and represents an accurate statement of fact. Name: Title: (Please Print Clearly) Signature: Date: N/AN/AN/A N/A - Not yet installed. To be included in design. DocuSign Envelope ID: 841533D9-ADB9-41B8-B07E-42D163C4D499 Ryan J. Schaefer 3/20/2023 Manager