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Company Name:     Type of Business:

Representative Name:  Phone number:   email address: 

Question Response
Waste Water  
Does the facility produce wastewater? Yes  No
What is the fate of this wastewater (ie, pretreatment, POTW, NPDES permitted discharge, hazardous or liquid industrial transporter)
Have you characterized your wastewater? Yes  No
How much wastewater is generated monthly? GAL
How much is currently spent on wastewater removal/treatment monthly? $
Storm Water  
Does the facility have a permit for the discharge of wastewater or stormwater? Yes  No
Has the facility implemented best management practices for stormwater runoff? Yes  No
Does the company have a stormwater pollution prevention plan (SWPPP)? Yes  No
Waste Oil  
Does the facility generate waste oil? Yes  No
How much waste oil is generated monthly? GAL
What is your monthly cost for waste oil removal? $
Are you purchasing more than 6 drums of any liquid product during a three-month period? Yes  No
Does the facility have routine maintenance for equipment? Yes  No
How much absorbent does the facility use monthly? Monthly expense?    $
What kinds of absorbents are used?  Check all that apply. Granular
Mats
Socks
Rags
Other:
Air Pollution  
Does the facility have equipment or processes that generate air pollution? (E.g., incinerator, boiler, solvent degreaser, paint booth, grinding operations, materials storage piles, etc.) Yes  No
How many active air permits does the facility have?
Do you have an inventory control system? Yes  No
Coolants  
Does the facility use any metalworking coolants? Yes  No
What is the amount of coolant used per month?  GAL
What is the amount of dirty coolant waste hauled per month?  GAL
Compressed Air  
Does the facility use compressed air? Yes  No
How old is the compressed air system?  YEARS
Are machines left running while not in use? Yes  No
Are there noticeable leaks in the system? Yes  No
Recycling Programs  
Does the facility have any office recycling programs? Yes  No
Does the facility have any shop floor recycling programs? Yes  No
What materials are reused/recycled? 
Training  
Does the company provide job specific training for employees? Yes  No
Does the company provide environmental health & safety training for employees? Yes  No
Is a record kept of the training completed by employees? Yes  No
Are the employees trained on emergency response? Yes  No
General  
What is the facility’s hazardous waste generation status?
What are the main uses of energy at the facility? (Include natural gas, diesel, electricity, etc)

  
What are the main uses of water at the facility?

  
Do you have any chemical conformance question that you would like help with?

  

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