Business New Service Pretreatment Questionnaire WATER WORKS and SANITARY SEWER BOARD Of the City of Montgomery Environmental Services 6000 Richard E. Hanan Drive Montgomery, AL 36108 COMPANY NAME: MAILING ADDRESS Street Address 1: Street Address 2: City: State: Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota N.W. Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Pr. Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Zip Code: BILLING ADDRESS Street Address 1: Street Address 2: City: State: Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota N.W. Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Pr. Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Zip Code: LOCATION OF BUSINESS IN MONTGOMERY, AL Street Address 1: Street Address 2: City: State: Alabama Alberta Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota N.W. Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Pr. Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Zip Code: Official Contact Name: Official Contact Phone: Your Name: Your Email: DESCRIPTION OF BUSINESS ACTIVITIES: DESCRIBE IN AS MUCH DETAIL AS POSSIBLE WHAT IS TO BE DISCHARGED TO THE SANITARY SEWER (EXCLUDE NORMAL SANITARY WASTEWATER) ESTIMATE THE QUANTITY IN GALLONS PER DAY OF WASTEWATER TO BE DISCHARGED (EXCLUDING NORMAL SANITARY WASTEWATER) LIST ANY PRETREATMENT FACILITIES TO BE USED AT THIS LOCATION EMBALMING SINK YESNO GARBAGE DISPOSALYESNO NUMBER OF HOUSING UNITS GREASE DRUMYESNO GREASE INTERCEPTORYESNO SIZE OF DEVICE GREASE TRAPYESNO GPM OF DEVICE: HOLDING TANK(S)YESNO OIL/WATER SEPARATORYESNO SAND TRAPYESNO SILVER RECOVERY UNITYESNO OTHER: REVIEW THE LIST OF PARAMETERS AND CIRCLE THE ONE(S) CONTAINED IN YOUR PRODUCTION/SERVICE ACTIVITYAcenaptheneEthylbenzeneAcroleinFluorantheneAcrylonitrileHalo ethersAldrin/DieldrinHalomethanesAntimony and compoundsHeptachlor and metabolitesArsenic and compoundsHexachlorocyclopentadieneAsbestosHexachlorocylohexaneBenzeneHexachloroutadieneBenzidineIsophoroneBeryllium and compoundsLead and compoundsCadmium and compoundsMercury and compoundsCarbon tetrachlorideMolybdenum and compoundsChlordaneNaphthaleneChlorinalkyl ethersNickel and compoundsChlorinated benzenesNitrobenzeneChlorinated ethanesNitrophenolsChlorinated naphthaleneNitrosaminesChlorinated phenolsPolychlorinated byphenyls (PCB)ChloroformPhenol2-chlorophenolPhentachlorophenolChromium and compoundsPhthalate estersCyanidesPolynuclear aromatics hydrocarbonsDDT and metabolitesSelenium and compoundsDichlorobenzenesSilver and compoundsDichlorobenzidine2,3,7,8,-Tetrachlorodibenzopdioxin2,4-dichlorophenolTetrachloroethyleneDichloropropaneThallium and compoundsDichloropropeneToluene2,4-dimethylphenolToxapheneDinitrotolueneTrichloroethyleneDiphenylhydrazineVinyl chlorideEndosulfan and metabolitesZinc and compoundsEndrin and metabolites LIST ANY TOXICANTS KNOWN OR ANTICIPATED TO BE PRESENT IN THE DISCHARGE. IT IS A GOOD IDEA TO CONSULT MATERIALS SAFETY DATA SHEETS (MSDS) FOR THE ABOVE LISTED PARAMETERS. THE WATER WORKS BOARD HAS AN AWARD WINNING BIOSOLIDS PROGRAM AND ASKS THAT METALS BE PARTICULARLY LOOKED AT FOR THIS QUESTIONNAIRE