2. A. General Information
4. Company Name (Discharger)
5. Mailing Address
7. Phone
8. Email
10. Project Manager
11. Company/Contractor (if different than discharger)
13. Project Manager Phone
14. Project Manager Email
16. Please provide the name and address of the entity responsible for related discharge fees.
18. Description of business activities (auto repair, machine shop, manfucaturing, etc.)
20. B. Wastewater Information
22. Description of wastewater (stormwater, ground water, process water, etc.)
24. Approximate voluame of wastewater to be discharged
25. Anticipated duration of discharge

    Please include date range

27. Estimated discharge flow rate
29. Is analytical data available?

    1. Yes
    2. No

    If yes, please provide the latest report to iwpp@charlestoncpw.com after submitting questionnaire.

31. The section below must be completed. Please select constituents below that are known or likely to be present in waste.
33. Acidic (pH<7)

    1. Yes
    2. No
34. Basic (pH>7)

    1. Yes
    2. No
35. Contains Heavy Metals (Lead/Copper/Arsenic/Etc)

    1. Yes
    2. No
36. Contains Inks or Dyes

    1. Yes
    2. No
38. Organic Compounds (Volatiles/Solvents)

    1. Yes
    2. No
39. Paints

    1. Yes
    2. No
40. Pesticides

    1. Yes
    2. No
41. PCBs

    1. Yes
    2. No
43. PFAs

    1. Yes
    2. No
44. Oil and Grease (Fats/Petroleum)

    1. Yes
    2. No
45. Total Suspended Solids (TSS) Greater Than 290 mg/l

    1. Yes
    2. No
46. Biochemical Oxygen Demand (BOD) Greater Than 290 mg/l

    1. Yes
    2. No
48. Other hazardous material (please specify)
50. C. Discharge Process
52. The discharge flow will be:

    1. Continuous
    2. Intermittent
    3. Pump & Haul

    Choose one

54. Estimated discharge flow rate.

    (Gallons per minute)

56. Discharge location

    Please submit a map of the project area including discharge location to iwpp@charlestoncpw.com after submitting questionnaire.

Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field