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Section I - General Information

Date*
Date
Is this a new application or a renewal?*
1. New
2. Renewal
Facility Site Information
Business Name*
Physical Address*
City
State
Zip Code
Mailing Address*
City
State
Zip Code
Business Phone Number*
Signatory Official Information
Signatory Official Requirements
Signatory Official Requirements (PDF)
Signatory First & Last Name*
Signatory Title*
Business Telephone Number*
Business Address*
City
State
Zip Code
Local Contact
Enter Local Contact information if different from Signatory Official
First & Last Name
Title
Business Telephone
Business Address
City
State
Zip Code
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Section II - Description of Activities

Section III - Facility Data / Property Information

Utility Account Location Numbers*
Customer Number*
Name on Utilities Account*
Address on Utilities Account*
Do you own or lease the property?*
1. Own
2. Lease
If leasing, name of property owner
Days & Hours of Operation
Sunday
Sunday Start Time
—
Sunday End Time
Monday
Monday Start Time
—
Monday End Time
Tuesday
Tuesday Start Time
—
Tuesday End Time
Wednesday
Wednesday Start Time
—
Wednesday End Time
Thursday
Thursday Start Time
—
Thursday End Time
Friday
Friday Start Time
—
Friday End Time
Saturday
Saturday Start Time
—
Saturday End Time
Is your facility located outside the City limits?*
1. Yes
2. No
Number of employees and/or people on site*
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Section IV - Water Usage

Section V - Wastewater Discharge Information

Section VI - Pretreatment Information

Acid Trap
Size
Location
Enzyme Injection
Size
Location
Food Grease Trap (Pot Type)
Size
Location
Food Grease Trap (Submerged)
Size
Location
pH Control
Size
Location
Sand / Lint Trap
Size
Location
Silver Reclaimer
Size
Location
Other
Please specify.
Size
Location
None
1. No Pretreatment
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Section VII - Facility Site Information

Cleaning Solutions
Acid Vat
Number of Pounds / Gallons
Location
Caustic / Jet Vat
Number of Pounds / Gallons
Location
Solvent Vat
Number of Pounds / Gallons
Location
Other Cleaning Solutions
Number of Pounds / Gallons
Location
Waste Oil
Number of Pounds / Gallons
Location
Asbestos / PCB / Radioactive
Number of Pounds / Gallons
Location
Machine Coolants
Number of Pounds / Gallons
Location
Paint Wastes/Filters
Number of Pounds / Gallons
Location
Waste Antifreeze
Number of Pounds / Gallons
Location
Waste Grease (Fryolator)
Number of Pounds / Gallons
Location
Waste Oil Filters
Number of Pounds / Gallons
Location
Other Waste Oil
Number of Pounds / Gallons
Location
Bulk Material Storage
Chemical Blending Tanks
Size
Location
Fuel Tank
Size
Location
Hazardous Waste
Size
Location
Non-Hazardous Material
Size
Location
Waste Grease (Fryolator)
Size
Location
Waste Oil
Size
Location
Other Bulk Material Storage
Size
Location
Material Safety Data Sheet
Please provide a Material Safety Data Sheet for each chemical stored in bulk on-site in quantities greater than 5 gallons and chemicals discharged to the wastewater collection system.
Spill Control Plan*
1. Yes
2. No
If yes, please provide a Spill Control Plan:
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Section VIII - Disposal Methods

Please provide documentation (e.g. manifests, waste receipts, etc.) concerning offsite disposal of all wastes or other than trash:
Include Waste Type, Transporter and Location
Has any of the wastes generated at this site been previously analyzed or classified as a hazardous waste?
1. Yes
2. No
If yes, please provide a copy of the classification and/or analytical results:
If you are discharging or requesting discharge of a hazardous waste ad defined by 40 CFR Part 261 to the wastewater collection system, you must notify the City of Odessa Pretreatment Division, the Environmental Protection Agency (EPA) Regional Waste Management Division Director, and the Texas Commission on Environmental Quality (TCEQ) Hazardous Waste Authority. this notification must include the name of the hazardous waste as set forth in 40 CFR Part 261, the EPA hazardous waste number, and the type of discharge (e.g. continuous, batch, etc). If you discharge more than 100 kilograms of the waste during a calendar month, you must contact the Pretreatment Division for additional reporting requirements and restrictions.
Does this facility have Texas Solid Waste Number?
1. Yes
2. No
If yes, provide number:
Does this facility have U.S. Environmental Protection Agency Registration Number?
1. Yes
2. No
If yes, provide number:
If applicable, provide a copy of the Texas or Environmental Protection Agency correspondence issuing the number:
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Section IX - Pollution Prevention Activities

Please list all pollution prevention activities you have incorporated or plant to incorporate into your business operations in the 3 years:*
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Section X - Compliance with Ordinance Requirements

To the best of my knowledge, the discharges from this facility will meet the requirements of the Sewage Quality Control Ordinance, Number 93-75 as amended.
1. Yes
2. No
Authorized Representative Statement
I certify under penalty of law that his document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or person who manage the system or those persons directly responsible for gathering the information, the information 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/or imprisonment for knowing violations.
Name*
Title*
Phone Number*
Date*
Date
Important Notice
The information provided in this application, other information submitted by your company, and information gathered by the City in conjunction with the operations and discharges from your company are subject to Open Records Requests. If any of the information submitted by your company is designated as confidential as defined by Section 552.110 of the Texas Public Information Act, you must assert it as such at the time of submission. Each page containing confidential information must be marked "Confidential Business Information". This information, if it is determined that it meets the criteria of the Texas Public Information Act, will be handled in accordance with the procedures described in the Act. If no claim of confidentiality is made at the time of submission, the information will be made available to the public without further notice.

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

This field is not part of the form submission.
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Wastewater Discharge Application

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Section I - General Information

Section II - Description of Activities

Section III - Facility Data / Property Information

Section IV - Water Usage

Section V - Wastewater Discharge Information

Section VI - Pretreatment Information

Section VII - Facility Site Information

Section VIII - Disposal Methods

Section IX - Pollution Prevention Activities

Section X - Compliance with Ordinance Requirements

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