Application for Authorization to Discharge Special Wastewater

BUTLER COUNTY WATER AND SEWER DEPARTMENT APPLICATION FOR AUTHORIZATION TO DISCHARGE SPECIAL WASTEWATER (Underground Storage Tanks)

Note to Property Owner / Signing Official

Information and data obtained from applications, permits, monitoring programs and inspections shall be available to the public or any government agency without restriction unless it can be demonstrated that the release of such information is entitled to the protection afforded by 40 CFR 403.14 entitled “Confidentiality”. Submission of this application form does not constitute permission to discharge wastewater. Separate discharge authorization documentation will be issued.

SECTION A- GENERAL INFORMATION

1. Organization Requesting the Evaluation (e.g. Consulting Firm)

A. Requestor’s Name: ______Telephone: (___)______B. Organization:______C. Mailing Address: ______

2. Location of Wastewater to be Discharged A. Address: ______

3. Current Property Owner A. Contact Name: ______Telephone: (___)______B. Company Name:______C. Mailing Address: ______

SECTION B- WASTEWATER CHARACTERIZATION

All industrial wastewater discharges shall be in compliance with the Butler County Sewer Use Rules.

Wastewater shall be discharged to an approved sanitary sewer location on the premises of the property. Wastewater discharges to storm sewers cannot be authorized by the Butler County Water and Sewer Department.

1. Proposed Wastewater Discharge

A. Source Description: ______B. Sewer Description:______C. Quantity: ______gallons D. Flowrate: ______gallons per minute E. Type of discharge: One Time  On-going  F. Expected Duration: ______G. Type of Pretreatment: ______

2. Wastewater Analyses The following pollutant concentrations shall be determined from a representative sample (grab type) in accordance with Ohio Environmental Protection Agency approved methods.

Pollutant

Total Lead Oil & Grease, Total Recoverable Total Petroleum Hydrocarbons pH *Ethyl-Benzene *Xylene *Toluene *Benzene

Notes: Laboratory analytical reports shall be submitted with Application. Additional analyses may be required as considered necessary. *Levels should be below the Bureau of Underground Storage Tank Regulations (BUSTR) action levels.

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

______Signature of Property Owner or Signing Official Date