Disclosure ‘A’ Form Make sure all blanks in Section I through section IV are completed. Complete a separate survey form for each facility or business that discharges to the city sewer. If needed, attach additional sheets keyed to section and item number to provide complete information. Signing official must have authorization to provide such information on behalf of the company, corporation, or partnership. SECTION I – GENERAL INFORMATION

A. INDUSTRIAL USER: Company Name: Division Name: Mailing Address: Contact: City/State: Phone: Zip Code: E-mail:

FACILITY: Name: Facility Address: City: State: Zip:

SIGNING OFFICIAL: Name: Mailing Address: City: State: Zip:

B. FACILITY USE INFORMATION Identify the type of business (es) conducted (auto repair, machine shop, electroplating,

painting, meat packing, restaurants, laundry services, etc.): _______________________________________________________________________ _______________________________________________________________________

# of Employees per shift: # of Shifts per day: Describe the manufacturing, production, or service activities this business conducts:

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City of Hayden Community & Economic Development / Public Works Departments

8930 N Government Way Hayden, ID 83835 www.cityofhaydenid.us (208) 209-2022

INDUSTRIAL WASTE PRETREATMENT APPLICATION

SECTION II – WASTE/WATER DATA

A. WATER SOURCES ( Please include all that apply) Estimated Measured Water Source MONTHLY FLOW PEAK HOURLY FLOW

(Gallons Per Day) (Gallons Per Minute) Municipal System (check one)

Avondale Irrigation District Hayden Lake Irrigation District North Kootenai Water District Other _____________________

Recycles Private Wells Other (Specify) _______________________

Total

B. SEPARATE METER FOR IRRIGATION (Check one) Yes No C. WATER USAGE GENERATES THE FOLLOWING TYPES OF WASTES (Please include all that apply) Estimated Measured

Identify generated waste types MONTHLY FLOW (Gallons Per Day)

PEAK HOURLY FLOW (Gallons Per Minute)

Domestic Waste (shower, restrooms, etc) Garbage Disposal (ground waste) Cooling Water (contact, non-contact) Boiler Water Process Water Equipment/Facility Wash Water (cleaning) Storm/water Runoff into Sewer Other: _____________________________

Total D. WASTEWATER DISCHARGES Estimated Measured (Please include all that apply)

Identify Waste/Water Disposal

MONTHLY FLOW (Gallons Per Day)

PEAK HOURLY FLOW (Gallons Per Minute)

Municipal Sewer Septic Tank Storm/water Surface or Groundwater Waste Hauler Evaporation Contained in Product Recycled Other (specify)__________________

Total E. DO YOU HAVE AN INJECTION WELL? Yes No F. DO YOU HAVE A SPILL PREVETION, CONTAINMENT, AND CONTROL PLAN (SPCC) FOR YOUR FACILITY? Yes No 2 of 5 8/16/2021

G. DO YOU DISPOSE OF ANY CHEMICALS, SOLVENTS, SLUDGES, OR HAZARDOUS MATERIALS TO LOCATIONS OTHER THAN MUNICIPAL SEWER WATERS?

Yes No

H. PROVIDE NAME AND ADDRESS OF WASTE HAULERS(S), IF ANY. ______________________________________________________________________________________________________________________________________________________________________ SECTION III – PLANT/PROCESS DATA A. RAW MATERIALS List all principal materials (cleaning agents, solvents, plating solutions, catalysts, etc.) that are regularly used in your facility, that might be present in your facility and that might be present in your wastewater discharge to a sanitary sewer.

GENERIC TYPE QUANTITY USED PER MONTH

PRINCIPAL CHEMICAL CONSTITUENTS (if known)

EXAMPLE: Degreaser 3 gallons Trichloroethylene B. PRODUCT(S) OR SERVICES. List all products manufactured or services provided by your facility along with the corresponding SIC (Standard Industrial Classification) code. If you do not know the SIC Code, contact Idaho Division of Environmental Quality at 1410 N Hilton, Boise, ID 83720, (208) 373-0502 or contact your local industrial pretreatment coordinator at (208) 772-4411.

Product Produced / Service Provided

Process 4-Digit SIC Code Amount / Average Rate of Production

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IV. WASTE/WATER CHARACTERISTICS A. PROCESSES: If your business employs processes in any of the 34 industrial categories or

business activities listed below and if any of these processes generate wastewater or waste sludge, place a check beside the category or business activity (check all that apply)

1. INDUSTRIAL CATAGORIES Adhesives Organic Chemicals Aluminum Forming Paint & Ink Auto & Other Laundries Pesticides Battery Manufacturing Petroleum Refining Coal Mining Pharmaceuticals Coil Coating Photographic Supplies Copper Forming Plastic & Synthetic Materials Electric & Electronic Components Plastic Processing Explosives Manufacturing Porcelain Enamel Foundries Printing & Publishing Gum & Wood Chemicals Pump & Paper Inorganic Chemicals Rubber Iron or Steel Soaps & Detergents Leather Tanning & Finishing Steam Electric Mechanical Products Textile Mills Nonferrous Materials Timber Ore Mining 2. OTHER BUSINESS ACTIVITY Dairy Products Slaughter/Meat Packing/Rendering Food/Edible Products Processing Beverage Bottler B. PRETREATMENT DEVICES OR PROCESSES USED FOR TREATING WASTEWATER OR SLUDGE (check all that apply). Air Flotation Neutralization, pH Correction Centrifuge Ozination Chemical Precipitation Reverse Osmosis Chlorination Screen Cyclone Sedimentation Filtration Septic Tank Flow Equalization Solvent Separation Grease or Oil Separation Type: ____________________________

Spill Protection

Grease Trap Size in Gallons: ____________________

Biological Treatment Type: _____________________________

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Grit Removal Rainwater Diversion or Storage Type: _____________________________

Ion Exchange Other Physical Treatment Type: _____________________________

Other Chemical Treatment Type: _____________________________

No Pretreatment Provided

Other: _____________________________ Type: _____________________________

OFFICE USE ONLY: SECTION V. COMPLIANCE WITH PRETREAMENT ORDINANCE A. Is industry in compliance with the city Industrial Pretreatment Ordinance?

Yes No Certified By: ________________________________________

Date: ______________________________________________

B. Is additional pretreatment required to comply with the ordinance?

Yes No

If yes, describe pretreatment needed: _______________________________________________________________________________ _______________________________________________________________________________

THE INFORMATION CONTAINED IN THIS DISCLOSURE FORM IS FAMILIAR TO ME, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF SUCH INFORMATION IS TRUE, COMPLETE, AND ACCURATE.

Signature: ____________________________________________ Date: ____________

Organization / Title: ______________________________________________________

Address: _______________________________________________________________

Telephone: _____________________________________________________________

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