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Form Dep / Dow - Pretreatment Annual Report For Publicly Owned Treatment Works - Kentucky Pollutant Discharge Elimination System - 2014 Page 3

IV. SIGNIFICANT INDUSTRIAL USER INFORMATION

(Complete Section IV for each SIU)

A. Industry Name:

B. Contact Person:

C. Mailing Address: 1. Street:

2. City:

3. State:

4. Zip Code:

D. Physical Address: 1. Street:

2. City:

3. State:

4. Zip Code:

E. Flow:

N/A

F. Batch Discharges:

N/A

1. Total Wastewater Flow (MGD):

1. Gallons per Batch:

2. Process Wastewater Flow (MGD):

2. Total No. of Batches this Report Period:

G. Federal Categorical Regulation Description

H. SIC/NAICS Codes:

(ex. 40 CFR 433.15 Metal Finishing, Subpart A):

N/A

Primary:

Secondary (if applicable):

I. Significant Non-Compliance (SNC):

N/A

Quarter 1 (Jan. – March)

Quarter 2 (April – June)

Quarter 3 (July – Sept.)

Quarter 4 (Oct. – Dec.)

J. Receiving WWTP KPDES No.:

K. Dates of Inspections

L. Oversight Sampling and Self-Monitoring:

Times Monitored

Noncompliance

Limit

Enforcement Actions(s)

Fine Amount

Parameter

Source

By POTW

By SIU

Frequency

Reason

(all that apply)

(if applicable)

Notes:

1. Explain if an annual inspection was not conducted.

Comments:

2. Parameters must include all KDOW approved local limits and

industrial user permit limits.

3. Mark “L” if the local limit was used and mark “C” if the categorical

limit was used, as applicable.

4. Explain if SIU didn’t sample permit limits more than two times per

year.

5. Enter “S” for pretreatment standards/limits violations and “R” for

reporting violations.

6. Do not include surcharges in this amount.

DEP / DOW

Revised October 2014

Form Dep / Dow - Pretreatment Annual Report For Publicly Owned Treatment Works - Kentucky Pollutant Discharge Elimination System - 2014 Page 3

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