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Home My WebLink AboutMA DEP Industrial Wastewater Holding Tank Compliance Certification FormMassachusetts Department of Environmental Protection wp56.doc 1/2017 Industrial Wastewater Holding Tank DEP Assigned Facility ID or Facility Name e c. DEP Assigned Facility ID Secondary Unit (e.g. Builtling•C, 711h Floor) 02673 h. Zip Code Secondary Unit m. Zip Code r Identification Number (FEIN or EIN) 5org. '!/ • s"� d. Telephone Number In. Telephone Number mation not answer questions that you wastewater ant cleaning wastewater Compliance Certification Form (WP 56) Important: When filling out forms A. Facility Information on the computer, use only the tab Cape Cod Ambulance key to move your a. Facility Name b. Facility SIC Cod cursor- do not 57 Mid -Tech Drive use the return key. d. Facility Site Address (Street No., Street Name, Street Suffix e.g. St, Ave, etc.) e. West Yarmouth MA f. City g. State i. Facility Mailing Address (If different from the facility site address above) j. ,z:.. k. City I. State 508-775-0494 �j`i-3o�/o$y n. Phone Number o. Fax Number p. Federal Employe A-1. Certification Information a. Contact Person First Name b. Contact Person Last Name C. Title Cape Cod Ambulance e. Owner First Name f. Owner Last Name g. Title i. General business description B. Industrial Wastewater and Holding Tank Infor Answer all questions, unless you are directed to skip a question. Do are directed to skip. 1. Major sources of industrial wastewater a. El Process (Check all that apply) b. ❑Equipm C. ❑Spent concentrated solution d. ®Floor spills or floor drainage e. [XI Othef(S) (Please describe below) Hand washing of vehicles major sources D rease Describe 2. Major pollutants in the industrial wastewater a. ❑BOD/CO (Check all that apply) b. ®Oil &G c. ❑Low/High pH M M d. E] Cyanide e. ❑Cadmiu f. ❑Chromiu g. El Copper h. El Lead L El Nickel j. El Silver k. El Zinc I. ❑ Other(s) Page 1 of 6 (Please describe below) Describe major pollutants Page 1 of 6 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (WP 56) Facility Name B. Industrial Wastewater and Holding Tank Information (Cont.) 3. Holding Tank ID (If any): 4. Holding Tank Installation Date: 5. Tank Type (Check one box only): 6. Tank Construction Material (Check appropriate box(es) or specify): 7. Tank Capacity (Check one box only): B -I. Compliance Information Section -1 General 101 Do you discharge industrial wastewater to a septic system, leaching field, or cesspool? 102 Do you discharge industrial wastewater to a storm drain or to the ground without a surface water or groundwater discharge permit? 103 Is the discharge of your industrial wastewater to a municipal sewer system feasible? (if your answer is yes to this question, you need to check with DEP for restrictions that may apply to your facility before completing this certification) 03/07/2018 (MM t DD / YYYY) a. ❑ Above -ground b. x❑ In -ground a. ❑ Steel b. ❑x Concrete c. ❑ Fiberglass d. ❑ Plastic e. ❑ Other(s) (Please describe below) Describe construction material a. E Less than 3,000 gallons b. ❑ 3,000 gallons or more ❑ yes — you must cease discharging and complete a Return to Compliance Plan KI no ❑ yes — you must cease discharging and complete a Return to Compliance Plan x❑ no ❑ yes — I have checked with DEP and I am aware of the restrictions that may apply to my facility ❑x no wp56.doc 1/2017 Page 2 of 6 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank _`:..... Compliance Certification Form (WP 56) B -I. Compliance Information (Cont.) 104 Is your facility located in the Zone I or Zone A of a drinking water supply area? (if your answer is yes to this question, you need to check with DEP for restrictions that may apply to your facility before completing this certification) 105 Is this certification for an above -ground holding tank? Section -2 Above -Ground Holding Tank 201 Is this above -ground holding tank constructed or lined with material compatible with your industrial wastewater? 202 Is this above -ground holding tank remotely filled or automatically filled? 202a Have you provided an appropriate audio and light alarm system for this above -ground holding tank? 203 Have you provided appropriate spill containment for this above -ground holding tank? 204 Have you provided "Non -Hazardous Industrial Wastewater' labels for this above -ground holding tank? 205 Was this above -ground holding tank bath installed after November 15, 2002 and fabricated on site? DEP Assigned Facility ID or Facility Name ❑ yes — I have checked with DEP and I am aware of the restrictions that may apply to my facility 0 no ❑ yes ❑x no - skip to question 301 ❑ yes ❑ no - submit a Return to Compliance Plan ❑ yes ❑ no - skip to question 203 ❑ yes ❑ no - submit a Return to Compliance Plan ❑ yes ❑ no - submit a Return to Compliance Plan ❑ yes ❑ no - submit a Return to Compliance Plan ❑ yes ❑ no - skip to question 401 wp56.doc 112017 Page 3 of 6 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank _..__.__._. Compliance Certification Form (WP 56) B -I. Compliance Information (Cont.) 205a Was this above -ground holding tank constructed in accordance with engineering plans that were stamped and signed by a Massachusetts Registered Professional Engineer? Section -3 In -Ground Holding Tank 301 Is this in -ground holding tank constructed or lined with material compatible with your industrial wastewater? 302 Is the capacity of this in -ground holding tank greater than 500% of the average daily flow? 303 Have you provided an appropriate audio and light alarm system for this in -ground holding tank? 304 Have you provided "Non -Hazardous Industrial Wastewater' labels or signs for this in -ground holding tank? 305 Was this in -ground holding tank installed before November 15, 2002? 305a Was this in -ground holding tank constructed in accordance with engineering plans that were stamped and signed by a Massachusetts Registered Professional Engineer? DEP Assigned Facility ID or Facility Name ❑ yes — skip to question 401 ❑ no— submit a Return to Compliance Plan and skip to question 401 x❑ yes ❑ no - submit a Return to Compliance Plan Z yes ❑ no - submit a Return to Compliance Plan Z yes ❑ no - submit a Return to Compliance Plan 0 yes ❑ no - submit a Return to Compliance Plan ❑ yes Z no - skip to question 306 El yes - skip to question 401 ❑ no wp56.doc 112017 Page 4 of 6 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank ____._..._. Compliance Certification Form (WP 56) B -I. Compliance Information (Cont.) 305b Will you (or did you) obtain an integrity assessment by November 15, 2003, which will be prepared by a Massachusetts Registered Professional Engineer, for this in -ground holding tank? 306 Was this in -ground holding tank constructed in accordance with engineering plans that were stamped and signed by a Massachusetts Registered Professional Engineer? 307 Have you provided an appropriate secondary containment for this in -ground holding tank? Section -4 Record Keeping 401 Do you maintain all holding tank construction and installation records (including all applicable permits) at the Facility? 402 Do you keep and maintain the appropriate operating records, including wastewater shipment, ultimate destination, and hauler information at the facility? DEP Assigned Facility ID or Facility Name ❑ yes - skip to question 401 ❑ no - submit a Return to Compliance Plan and skip to question 401 ❑ yes ❑ no - submit a Return to Compliance Plan ❑ yes ❑ no - submit a Return to Compliance Plan 0 yes ❑ no - submit a Return to Compliance Plan I] yes ❑ no - submit a Return to Compliance Plan wp56.doc 1/2017 Page 5 of 6 Massachusetts Department of Environmental Protection ;. Industrial Wastewater Holding Tank DEP Assigned Facility ID or Compliance Certification Form (WP 56) Facility Name C. Certification Statement (Note: Complete all required Return to Compliance Plan forms before signing this statement) "I, , V ,,j —, attest under the pains and penalties of perjury: (Name of responsible official) (i) that I have personally examined and am familiar with the information contained in this submittal, including any and all documents accompanying this certification statement; (ii) that, based on my inquiry of those individuals responsible for obtaining the information, the information contained in this submittal is to the best of my knowledge, true, accurate, and complete; (iii) that systems to maintain compliance are in place at the facility and will be maintained even if processes or operating procedures are changed; and (iv) that I am fully authorized to make this attestation on behalf of this facility. I am aware that there are significant penalties including, but not limited to, possible fines and imprisonment for willfully submitting false, inaccurate, or incomplete information." Signature ` Printed Name Source of Signatory Authority (Check appropriate box): 1. If a Corporation: / Z P3120Y,�- Date (dMI l DO'/ YYY,Y ) ♦n� �e Title a. ❑ President b. ❑ Secretary c. ❑ Treasurer d. ❑ Vice President (if authorized by corporate vote) e. (/'Representative of the above (if authorized by corporate vote and if responsible for overall operation of the facility) 2. If a Partnership: ❑ General Partner 3. If a Sole Proprietorship: ❑ Proprietor 4. If an Institution: ❑ Principal Executive Officer 5. If a Municipality or a Public Agency: a. ❑ Principal Executive Officer b. ❑ Ranking Elected Official (Empowered to enter into contracts on behalf of the municipality or public agency) wp56.doc 1/2017 Page 6 of 6