(Trade E3luent Notice) Section 119 Water Industry Act (1991) GL322010 WBSM-1L6111-1000 Application for a Temporary Trade E3luent Discharge Consent *please refer to guidance notes Section A: Reason for application A1. Reason for applying for a temporary discharge consent: A2. Date you are proposing to start discharging? / / ......................................................................................................................................................................................... X X X X 2 0 1 4 A3. What is the proposed end date? ......................................................................................................................................................................................... X X / X X / 2 0 1 4 ......................................................................................................................................................................................... A4. Have you had a temporary discharge licence from Southern ......................................................................................................................................................................................... Water before? Yes No *Section B: Company details (Legal entity responsible for consent) Must not be consultant or agent acting on behalf of discharger B1. Company trading name: ........................................................................................................... B4. Contact name: ..................................................................................................................................... B2. Address: ...................................................................................................................................................... B5. Landline number: ............................................................................................................................ ......................................................................................................................................................................................... B6. Mobile: ......................................................................................................................................................... B3. Postcode: ................................................................................................................................................... B7. Email: .............................................................................................................................................................. Section C: Site details (Premises from where the temporary discharge will be made) *C1. Nature of business conducted on site? *Contact for invoicing purposes: ......................................................................................................................................................................................... C10. Address (if different from site): ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... C11. Postcode (if different from site): .................................................................................... *C2. Trading name: ................................................................................................................................... C12. Contact name: ................................................................................................................................... *C3. Address: ................................................................................................................................................... C13. Job title: .................................................................................................................................................... ......................................................................................................................................................................................... C14. Landline number: .......................................................................................................................... *C4. Postcode: ................................................................................................................................................ C15. Mobile: ....................................................................................................................................................... *Contact for Trade E3luent purposes: C16. Email: .......................................................................................................................................................... C5. Contact name: ..................................................................................................................................... C6. Job title: ...................................................................................................................................................... C7. Landline number: ............................................................................................................................. C8. Mobile: ......................................................................................................................................................... C9. Email: ............................................................................................................................................................. Continues on next sheet 1 Section D: Trade E3luent Discharge details *D1. What process(es) does the trade eDluent come from? ......................................................................................................................................................................................... (e.g. site commissioning work, tank testing, groundwater discharge, pipework flushing/disinfection) ......................................................................................................................................................................................... Please enclose Material Safety Data Sheet (MSDS) for any chemicals used in the process: ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... *D3. Does the trade eDluent have any pre-treatment prior to ......................................................................................................................................................................................... discharge? Yes No ......................................................................................................................................................................................... If so, what? Please enclose a plan showing the position of the ......................................................................................................................................................................................... pre-treatment plant on site: ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... ........................................................................................................................................................................................