The URL can be used to link to this page

Home My WebLink AboutSupporting Documentation - 09/03/2025S:\OPERATIONS\Pretreatment\Forms\Industrial-Waste-Questionnaire-2015.docx (1) INDUSTRIAL WASTE QUESTIONNAIRE ACCOUNT#: TELEPHONE: FAX:___________________ EMAIL ADDRESS: __________________ INDIVIDUAL RESPONSIBLE FOR FACILITY OPERATION: INDIVIDUAL PROVIDING INFORMATION: 2.TYPE OF BUSINESS:MANUFACTURING  SALES  SERVICE  (please check)DISTRIBUTION  OTHER  DESCRIBE YOUR FACILITY’S ACTIVITY: LIST PRINCIPAL PRODUCTS OR SERVICES: LIST RAW MATERIALS USED: LIST PROCESSES INVOLVED: STANDARD INDUSTRIAL CLASSIFICATION CODE(S) FOR MANUFACTURING AND SERVICE INDUSTRIES (Sample SIC listed on Final Page of Questionnaire): IS BUSINESS SUBJECT TO SEASONAL VARIATION:  YES  NO IF YES, INDICATE MONTHS OF PEAK OPERATION:__________________________________________ 3.WILL LANDSCAPE BE IRRIGATED? YES  NO IS THERE AN IRRIGATION METER PRESENT?  YES  NO 3201 E Mulberry St, Unit Q PO Box 1518 Fort Collins, CO 80522 Phone: 970-498-0604 Fax: 970-498-0701 Email: bsdacctg@boxeldersanitation.org S:\OPERATIONS\Pretreatment\Forms\Industrial-Waste-Questionnaire-2015.docx (2) 4.METHOD OF WASTEWATER DISPOSAL (check): MUNICIPAL SEWER  SEPTIC TANK  HAUL  If answer is "Septic Tank," do not complete the remainder of this questionnaire. If answer is “Haul”: list hauler name, address and frequency of pick up: TYPE OF WASTEWATER DISCHARGED INTO MUNICIPAL SEWER (check one or both): DOMESTIC  INDUSTRIAL  Note: "Domestic" wastewater includes wastewater produced from the non-commercial preparation of food, or wastewater containing only human excrement and similar matter from the sanitary conveniences of dwellings and commercial, industrial or institutional buildings. All other wastewater should be considered "industrial." Check all activities occurring at these premises, including primary services and processes (CIU determination): 5.DOES YOUR ACTIVITY INVOLVE THE USE OF ANY OF THE FOLLOWING: (Place an "X" in the appropriate box) (incl. cooling/boiler sys.) S:\OPERATIONS\Pretreatment\Forms\Industrial-Waste-Questionnaire-2015.docx (3) 6. IF ANY OF THE ABOVE CONSTITUENTS ARE DISCHARGED OR PROPOSED TO BE DISCHARGED INTO THE PUBLIC SANITARY SEWER, INDICATE WITH (X) IN THE FAR RIGHT HAND COLUMN ABOVE. 7. DO THE CONTAINERS OF THE SOLUTIONS OR MATERIALS USED IN YOUR MANUFACTURING, CLEANING, OR OTHER OPERATIONS BEAR ANY HAZARD WARNING LABELS OR MSDS? IF SO, PLEASE INDICATE NAME OF SOLUTION OR MATERIAL. 8. IS YOUR WASTEWATER TREATED BEFORE IT LEAVES YOUR FACILITY? (circle) YES i.e., sediment interceptor, oil separator, etc. NO IF YES, WHAT KIND OF TREATMENT? 9. ARE THERE EVAPORATIVE COOLING TOWERS, COOLING SYSTEMS, CHILLERS OR BOILERS INSTALLED ON-SITE? YES NO 10. ARE THERE ANY FLOOR DRAINS IN THE WORK AREAS? (circle) YES NO 11.DO YOU ANTICIPATE ANY CHANGES IN OPERATION IN THE FUTURE? (circle) If yes, please explain. YES NO 12.ESTIMATE THE TOTAL WATER USAGE AT YOUR BUSINESS. SOURCE OF INFORMATION (check one) AVERAGE MONTHLY GALLONS W ater Bill Estimate Other* Winter Summer *Please explain. 13.ATTACH A COPY OF ANY CHEMICAL ANALYSES PERFORMED ON YOUR WASTEWATER FLOWS WITHIN THE LAST THREE YEARS. ANALYSES ATTACHED  NO ANALYSES AVAILABLE  14.DOES THE UNIT HAVE ITS OWN SEPARATE DISCHARGE POINT (toilets, sinks, drains)?  yes  no NOTE TO SIGNING OFFICIAL: In accordance with Title 40 of the Code of Federal Regulations Part 403 Section 403.14, effluent data provided in this questionnaire shall be available to the public without restriction. Any other information provided may be claimed as confidential by the submitter. Such claim must be asserted at the time of submission by stamping the words "Confidential Business Information" on each page containing confidential data or information, or similarly identifying the information claimed as confidential. Requests for confidential treatment of information shall be governed by procedures specified in 40 CFR Part 2. I have examined and am familiar with the information submitted in this document, and certify that the information is complete, and represents an accurate statement of fact to the best of my knowledge. NAME TITLE SIGNATURE DATE STANDARD INDUSTRIAL CLASSIFICATION CODES (SIC #) FOR MANUFACTURING AND SERVICE INDUSTRIES S:\OPERATIONS\Pretreatment\Forms\Industrial-Waste-Questionnaire-2015.docx SIC # INDUSTRY GROUP SERVICES 491 Electric Services 492 Gas Production and Distribution 493 Combination Electric, Gas, and Other Utility Services 721 Laundry, Cleaning, and Garment Services 7391 Research and Development Laboratories 8731 Commercial Physical Research 8732 Commercial Non-Physical Research 7384 Photofinishing Laboratories 7532 Automotive Body, and Painting Shops 7538 Automotive Repair Shops 7542 Car Washes 8011 Medical Offices 8021 Dental Offices 806 Hospitals 807 Medical and Dental Laboratories MANUFACTURING FOOD AND KINDRED PRODUCTS 201 Meat Products 202 Dairy Products 203 Canned and Preserved Fruits and Vegetables 204 Grain Mill Products 205 Bakery Products 206 Sugar and Confectionery Products 207 Fats and Oils 208 Beverages 209 Miscellaneous Food Preparations and Kindred Products TOBACCO MANUFACTURES 21 All categories TEXTILE MILL PRODUCTS 22 All categories APPAREL AND OTHER FINISHED PRODUCTS MADE FROM FABRICS AND SIMILAR MATERIALS 23 All categories LUMBER AND WOOD PRODUCTS, EXCEPT FURNITURE 2491 Wood Preserving, Particleboard 24 All other categories FURNITURE AND FIXTURES 25 All categories PAPER AND ALLIED PRODUCTS 251 Pulp Mills 262 Paper Mills, Except Building Paper Mills 263 Paperboard Bills 265 Paperboard Containers and Boxes 267 Converted Paper and Paperboard Products, Except Containers and Boxes 2679 Converted Paper and Paperboard Products, not elsewhere classified SIC # INDUSTRY GROUP MANUFACTURING (Cont'd) PRINTING , PUBLISHING, AND ALLIED INDUSTRIES 27 All categories CHEMICALS AND ALLIED PRODUCTS 281 Industrial Inorganic Chemicals 282 Plastics Materials and Synthetic Resins, Synthetic Rubber, Synthetic and Other Man-made Fibers, except Glass 283 Drugs 284 Soap, Detergents, and Cleaning Preparations, Per-fumes, Cosmetics, and Other Toilet Preparations 285 Paints, Varnishes, Lacquers, Enamels, and Allied Products 286 Industrial Organic Chemicals 287 Agricultural Chemicals 289 Miscellaneous Chemical Products PETROLEUM REFINING AND RELATED INDUSTRIES 291 Petroleum Refining 295 Asphalt Paving and Roofing Materials 299 Miscellaneous Products of Petroleum and Coal RUBBER AND MISCELLANEOUS PLASTICS PRODUCTS 301 Tires and Inner Tubes 302 Rubber and Plastics Footwear 3052 Rubber and Plastics Hose and Belting 306 Fabricated Rubber Products, not elsewhere classified 308 Miscellaneous Plastics Products LEATHER AND LEATHER PRODUCTS 311 Leather Tanning and Finishing 31 All other categories STONE, CLAY, GLASS AND CONCRETE PRODUCTS 32 All categories PRIMARY METAL INDUSTRIES 331 Blast Furnaces, Steel Works, and Rolling and Finishing Mills 332 Iron and Steel Foundries 333 Primary Smelting and Refining of Non- ferrous Metals 334 Secondary Smelting and Refining of Non-ferrous Metals 335 Rolling, Drawing, and Extruding of Non- ferrous Metals 336 Nonferrous Foundries (Castings) 339 Miscellaneous Primary Metal Products SIC # INDUSTRY GROUP MANUFACTURING (Cont'd) FABRICATED METAL PRODUCTS, EXCEPT MACHINERY AND TRANSPORTATION EQUIPMENT 341 Metal Cans and Shipping Containers 342 Cutlery, Hand Tools, and General Hardware 343 Heating Equipment, Except Electric and Warm Air; and Plumbing Fixtures 344 Fabricated Structural Metal Products 345 Screw Machine Products, and Bolts, Nuts, Screws, Rivets, and Washers 346 Metal Forgings and Stampings 347 Coating, Engraving, and Allied Services 348 Ordnance and Accessories, Except Vehicles and Guided Missiles 349 Miscellaneous Fabricated Metal Products MACHINERY, EXCEPT ELECTRICAL 351 Engines and Turbines 352 Farm and Garden Machinery and Equipment 353 Construction, Mining, and Materials Handling Machinery and Equipment 354 Metalworking Machinery and Equipment 355 Special Industry Machinery, Except Metalworking Machinery 356 General Industrial Machinery and Equipment 357 Office and Computing Equipment 358 Refrigeration and Service Industry Machinery 359 Miscellaneous Industrial and Commercial Machinery and Equipment ELECTRICAL AND ELECTRONIC MACHINERY, EQUIPMENT, AND SUPPLIES 361 Electric Transmission and Distribution Equipment 362 Electrical Industrial Apparatus 363 Household Appliances 364 Electric Lighting and Wiring Equipment 365 Household Audio and Video Equipment, and Audio Recordings 366 Communication Equipment 367 Electronic Components and Accessories 369 Miscellaneous Electrical Machinery, Equipment, and Supplies TRANSPORTATION EQUIPMENT 37 All categories MEASURING, ANALYZING, AND CONTROLLING INSTRUMENTS; PHOTOGRAPHIC, MEDICAL, AND OPTICAL GOODS; WATCHES AND CLOCKS 38 All categories