NAPA SANITATION DISTRICT

( )Carb. Cleaner ( )Paint ( )Trans.<br><br> Oil ( )Detergents ( )Solvents ( )Anti-Freeze ( )Thinner ( )Waxes ( )Gasoline ( )Battery Acid ( )Grease ( )Degreasers ( )Diesel ( )Brake Fluid ( )Caustics ( )None ( )Other_______________________________________________________________ 11. Name, Address, Facility Contact, Phone Number, and Permit Number of firm that hauls spent oil, anti-freeze, or other wastes from your facility. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 12.<br><br> Location of discharge(s): Describe process discharges for each: Sewer _____________________________________________________ Storm _____________________________________________________ Landscape _____________________________________________________ 13. Is there a sand/oil separator connected to sanitary sewer? ( )yes ( )no ( ) permanently sealed Other ( ) ___________________________ At what process location in the facility:_________________________________ E.g.<br><br> service area, auto washing, auto body repair area, parts. 14. Are there floor drains at your facility?<br><br> ( )yes ( )no ( ) permanently sealed At what location in this facility? _______________________________________ E.g. service area, auto washing, auto body repair area, parts.<br><br> 15. Where are chemicals stored? ( )indoors ( )outdoors ( )covered ( )uncovered ( )concrete ( )asphalt ( )soil ( )locked ( )unlocked 16.<br><br> Are MSDS available for all materials at the facility? ( )yes ( )no 17. Is emergency equipment available in case of a spill?<br><br> ( )yes ( )no Please list:_______________________________________________________ 18. Are good housekeeping procedures in effect? ( )yes ( )no 19.<br><br> Are incompatible chemicals/materials being stored properly? ( )yes ( )no 20. Do you have a written waste minimization/pollution prevention plan?<br><br> ( )yes ( )no 21. Has a waste minimization/pollution prevention audit been performed at this site? ( )yes ( )no CERTIFICATION: "I certify under penalty of penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted.<br><br> Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." Signature_________________________________ Date________________________ Name (type or print)______________________ Title___________________________ H:\BGaffney\Pretreatment\Industrial Users\AUTO\PRMTAPPL.DOC

less