Form Dep / Dow - Pretreatment Annual Report For Publicly Owned Treatment Works - Kentucky Pollutant Discharge Elimination System - 2014

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KENTUCKY POLLUTANT DISCHARGE
ELIMINATION SYSTEM
Pretreatment Annual Report
For Publicly Owned Treatment Works
Submission of this Pretreatment Annual Report is a required condition of your Kentucky Pollutant Discharge Elimination
System (KPDES) permit(s).
The 2014 Annual Report is for the entire 2014 calendar year (January 1 to December 31).
A typed and complete Pretreatment Annual Report must be received by March 1, 2015. All entries must be filled out
completely, or the report will be considered deficient. Failure to submit the report by the deadline may result in enforcement
action, and the control authority may be considered to be in significant noncompliance.
Should you have any questions, contact your designated Division of Water Pretreatment Coordinator at (502) 564-3410.
ALL INFORMATION MUST BE PROVIDED ON THIS FORM, UNLESS PRIOR, APPROVED ARRANGEMENTS
HAVE BEEN MADE.
I. CONTROL AUTHORITY INFORMATION
A. Name of Control Authority:
B. Wastewater Treatment Plant Name(s):
KPDES Number(s):
County:
1.
2.
3.
II. PRETREATMENT PROGRAM CONTACT INFORMATION
A. Name:
B. Title:
C. Phone:
D. E-mail Address:
E. Mailing Address:
1. Street:
2. City:
3. State:
4. Zip Code:
DEP / DOW
Revised October 2014
1

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