Welcome - Kentucky Energy and Environment Cabinet



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| |KENTUCKY POLLUTANT DISCHARGE |

|[pic] |ELIMINATION SYSTEM |

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| |Pretreatment Annual Report |

| |For Publicly Owned Treatment Works |

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|Submission of the 2019 Pretreatment Annual Report is a required condition of your Kentucky Pollutant Discharge Elimination System (KPDES) permit(s). The 2019 |

|Annual Report is for the entire 2019 calendar year (January 1 – December 31). |

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|A typed and complete Pretreatment Annual Report must be received by March 1, 2020. All entries must be filled out completely, or the report may be considered |

|deficient. This form is located on the pretreatment page of the Division of Water’s new |

|website: . It must be submitted as one, single .pdf file through the |

|Pretreatment Section of the DEP/DOW ePortal at .  If you have any questions regarding submitting the report |

|through the ePortal, send an email to the ePortal helpdesk at DEPTempoSA@.   |

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|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. |

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|I. CONTROL AUTHORITY INFORMATION |

|Name of Control Authority (not the name of the WWTP):       |

|Wastewater Treatment Plant Name(s): |KPDES Number(s): |County: |

|      |      |      |

|      |      |      |

|      |      |      |

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|II. PRETREATMENT PROGRAM CONTACT INFORMATION |

|Name:       |

|Title:       |

|Phone:       |

|E-mail Address:       |

|Mailing Address: |

|Street:       |

|City:       |State:       |Zip Code:       |

| |

|III. PRETREATMENT PERFORMANCE SUMMARY |

|Significant Industrial User Compliance |

| |Categorical | |Noncategorical |

|Number of SIUs Permitted |      | |      |

|Number of SIUs Required to Submit Self-Monitoring Reports |      | |      |

|Number of SIUs in SNC with Reporting |      | |      |

|Number of SIUs in SNC with Pretreatment Standards |      | |      |

|Number of SIUs in SNC with Reporting but not Sampled or Inspected |      | |      |

|Number of SIUs in SNC with Compliance Schedule |      | |      |

| | | | |

|Compliance Monitoring Program | | | |

| |Categorical | |Noncategorical |

|Number of SIUs with Current Permits |      | |      |

|Number of Complete, Documented Inspections Conducted |      | |      |

|Number of Facilities Inspected |      | |      |

|Number of Sampling Events Conducted by the Control Authority |      | |      |

|Number of Facilities Sampled |      | |      |

|Number of SIUs not Sampled or Inspected |      | |      |

| | | | |

|Enforcement Actions | | | |

| |Categorical | |Noncategorical |

|Number of SIUs Issued Any Enforcement Actions |      | |      |

|Number of Notices of Violation Issued to SIUs |      | |      |

|Number of SIUs From Which Fines Have Been Collected |      | |      |

|Amount of Fines Collected (Do not include surcharges) |$      | |$      |

|Number of Administrative Orders Issued to SIUs |      | |      |

|Number of SIUs on Compliance Schedules |      | |      |

|Number of Civil Suits Filed |      | |      |

|Number of Criminal Suits Filed |      | |      |

|Number of SIUs Published in Newspaper during the reporting period |      | |      |

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| |Comments: |

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|IV. INDUSTRIAL USER INFORMATION SHEETS |

|An Industrial User Information Sheet must be completed for ALL industrial users including: |

|SIUs |

|CIUs |

|NCSIUs |

|Zero-discharge IUs |

|General permittees |

|Any other permitted industry, excluding gas stations, restaurants and commercial establishments. |

| |

|A blank IU sheet is included. |

| |

|V. NARRATIVE SUMMARY OF PRETREATMENT PROGRAM |

|Treatment Works |

|Did the Control Authority experience any of the following that was caused by industrial users during 2019? |

|Interference | Yes No |

|Pass Through | Yes No |

|Fire or explosions | Yes No |

|Corrosive structural damage | Yes No |

|Flow obstruction | Yes No |

|Excessive flow rates | Yes No |

|Excessive pollutant concentrations | Yes No |

|Heat problems | Yes No |

|Interference due to oil and grease | Yes No |

|Toxic fumes | Yes No |

|Illicit dumping of hauled wastes | Yes No |

|Worker health safety | Yes No |

| Sludge/biosolids | Yes No |

|KPDES permit violation |Yes No |

|Other (specify:      ) | Yes No |

|Describe the corrective actions taken and the name and address, if known, of the industrial user(s) responsible. |

| N/A |

|      |

|Fats, Oils, and Grease |

|Have any problems at the treatment works been caused by Fats, Oils, or Grease? | Yes No |

|Does the Control Authority currently have a Fats, Oils, and Grease program or is it in the process of developing a program? | Yes No |

|List all current industrial users that have been or will be deleted from the Pretreatment Program and explain the reason for the deletion. Describe actions taken to |

|ensure that there is no reasonable potential for discharge to the POTW. |

| N/A |

|      |

|List all industrial users that were added to the Pretreatment Program in the past year, and indicate if the industry is categorical and/or significant. Indicate if you |

|plan to add any industries in the next six (6) months and if the industry is categorical and/or significant. |

| N/A |

|      |

|List ALL waste haulers, including Significant Industrial Users, such as landfills, that discharge to the POTW. Include the following | N/A |

|information: | |

|Industry Generating the |Permitted |Waste Hauler |Permitted |Description/Type of Hauled |Method for |Point of Discharge |

|Hauled Waste | | | |Waste |Verifying Loads |at WWTP |

|      | Yes No |      | Yes No |      |      |      |

|      | Yes No |      | Yes No |      |      |      |

|      | Yes No |      | Yes No |      |      |      |

|      | Yes No |      | Yes No |      |      |      |

|      | Yes No |      | Yes No |      |      |      |

|Provide the following information regarding SIU compliance schedules (CS) that are currently in effect: | N/A |

|SIU Name |Date Issued |Completion Date |Reason for CS |

|      |      |      |      |

|      |      |      |      |

|Significant Non-Compliance |

|List all industrial users which were in significant noncompliance (SNC): | N/A |

|IU Name |Reason for SNC |Total number of |Action taken by IU |

| | |months in SNC |to achieve compliance |

|      |      |      |      |

|      |      |      |      |

|Attach a copy of the publication tear sheet. | N/A |

|      |

|Did the Control Authority make any of the following changes to the Pretreatment Program? Describe the changes. |

| |

|Administrative structure | Yes No |

|      |

|Local Discharge Limitations | Yes No |

|      |

|Monitoring Parameters/Frequencies in Industrial User Permits | Yes No |

|      |

|Legal Authority or Enforcement Policy | Yes No |

|      |

|Funding mechanism, resource requirements or staffing levels | Yes No |

|      |

|Describe the current sludge disposal method(s) and any proposed or planned changes. |

|      |

|Estimate the annual budget for the Pretreatment Program. |

|$      |

|List all multi-jurisdictional agreements, industrial user contracts, agreements or any other document that extends the Control | N/A |

|Authority’s legal authority. Identify the SIUs covered by each. | |

|      |

|General Comments: |

|      |

| Local Limits |

|**Please note the changes in this section** |

|Include local limits changes that occurred between 01/01/2019 and 12/31/2019 (the reporting period). Select N/A if no changes were made during 2019. Please use |

|MM/DD/YYYY format for the dates. |

|Enter the most recent date on which the Control Authority completed a local limits re-evaluation or revised local limits during the reporting period:       N/A |

|Enter the most recent date on which the Control Authority adopted new local limits within the reporting period:       N/A |

|Explain if a re-evaluation has not been completed within 5 years from the last re-evaluation and provide the estimated timing to submit a re-evaluation:       N/A |

|List all pollutants for which local limits have been established. Do not include surchargeable parameters.       |

| |

|Comments:       |

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|VI. ANNUAL SCAN SUMMARY       (year) |

|KPDES Permit Number:       | | | | |

| | | |Frequency|Sample Type |

| | | |1 | |

| | |Quality or Concentration |Quantity or | |Grab |24 Hr |

| | | |Loading | | |Comp |

| |Units |Average |Daily Maximum|Annual Total| | | |

|Arsenic, Total Recoverable |Effluent |

|Frequency must be, at a minimum, annual. |      |

|This form must be filled out completely. If the results are below detection | |

|limits, indicate so. | |

|This form must be completed even if information has been submitted to meet other | |

|KPDES permit requirements. | |

|The grayed out cells do not have to be completed. | |

| |

|IV. CERTIFICATION STATEMENT |

|I certify under penalty of law that this 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 persons who manage the system, or |

|those persons directly responsible for gathering the information, the information submitted 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 imprisonment for knowing violations. |

|Name: |

|Mr. Ms.       |

|Title:       |

|Phone:       |

|Email:       |

|Mailing Address: |

|Street:       |

|City:       |State:       |Zip Code:       |

|Signature: |Date: |

| |      |

| | |

| | |

|(This must be hand signed or | |

|signed with an electronic signature.) | |

| |

|Notes: | |

|Federal and state statutes provide for severe penalties for submitting false information in this report. Federal and state regulations require this report to be |

|signed by a principal executive officer, ranking elected official or other duly authorized employee. The duly authorized employee must be an individual or |

|position having responsibility for the overall operation of the Pretreatment Program. |

Completed report form and supplemental attachments must be electronically submitted through the Division of Water’s ePortal: .

|IV. INDUSTRIAL USER INFORMATION |

| SIU CIU NSCIU Non-SIU (Complete an Industrial User Information Sheet for each IU.) |

|Industry Name:       |Contact Person:       |

|Mailing Address: 1. Street:       2. City:       3. State:       4. Zip Code:       |

|Physical Address: 1. Street:       2. City:       3. State:       4. Zip Code:       |

|IU Permit:       Effective date of permit       Expiration date of permit Expired permit Not permitted |

|Flow: N/A |Batch Discharges: N/A |

|Total Wastewater Flow (MGD):       |Gallons per Batch:       |

|Process Wastewater Flow (MGD):       |Total No. of Batches this Report Period:       |

|Federal Categorical Regulation Description : N/A |SIC/NAICS Codes: |

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

|      |Secondary (if applicable):       |

|      | |

|Significant Non-Compliance (SNC): N/A | |

| Quarter 1 (Jan. – March) | Quarter 2 (April – June) | Quarter 3 (July – Sept.) | Quarter 4 (Oct. – Dec.) |

| Published during reporting period | To be published during next reporting period | N/A |

|Receiving WWTP KPDES No.:       |Dates of Inspections 1:       |

|Oversight Sampling and Self-Monitoring: | CA samples in lieu of SIU for all self-monitoring requirements.7 |

| |CA samples in lieu of SIU for some of the self-monitoring requirements. 7 |

| |CA samples in lieu of SIU for select parameters. 7 |

|Parameter 2 |Limit Source|Times Monitored |Noncompliance |Enforcement Actions(s) |Fine Amount 6 |

| |3 | | |(all that apply) |(if applicable) |

| | |By POTW |By SIU 4 |Frequency |Reason 5 | | |

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|Notes: |

|Explain if an annual inspection was not conducted. |Comments: |

| |      |

|Parameters must include all KDOW approved local limits and industrial user permit limits. | |

|Mark “L” if the local limit was used and mark “C” if the categorical limit was used, as | |

|applicable. | |

|Explain if SIU sampled permit limits less than twice per year. | |

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

|Do not include surcharges in this amount. | |

|Describe how the CA samples in lieu of the SIU. | |

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