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Home My WebLink Aboutwp56app Compliance Form - TL signed 5-10-24 (003)wp56.doc 3/2020 Page 1 of 5 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank Compliance Certification Form (WP 56) Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. Facility Information a. Facility Name b. Facility SIC Code c. DEP Assigned Facility ID d. Facility Site Address (Street No., Street Name, Street Suffix e.g. St, Ave, etc.)e. Secondary Unit (e.g. Building-C, 7th Floor) f. City g. State h. Zip Code i. Facility Mailing Address (If different from the facility site address above)j. Secondary Unit k. City l. State m. Zip Code n. Phone Number o. Fax Number p. Federal Employer Identification Number (FEIN or EIN) A-I. Certification Information a.Contact Person First Name b.Contact Person Last Name c. Title d. Telephone Number e. Owner First Name f. Owner Last Name g. Title h. Telephone Number i.General business description B. Industrial Wastewater and Holding Tank Information Answer all questions, unless you are directed to skip a question. Do not answer questions that you are directed to skip. 1.Major sources of industrial wastewater (Check all that apply) a.Process wastewater b.Equipment cleaning wastewater c.Spent concentrated solution d.Floor spills or floor drainage e.Other(s) (Please describe below) 2.Major pollutants in the industrial wastewater (Check all that apply) a.BOD/COD b.Oil & Grease c.Low/High pH d.Cyanide e.Cadmium f.Chromium g.Copper h.Lead i.Nickel j.Silver k.Zinc l.Other(s) (Please describe below) Please do not mail. Submit through ePlace. See instructions. wp56.doc 3/2020 Page 2 of 5 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank Compliance Certification Form (WP 56) DEP Assigned Facility ID or Facility Name B. Industrial Wastewater and Holding Tank Information (Cont.) 3.Holding Tank ID (If any): 4.Holding Tank Installation Date: (MM / DD / YYYY) 5.Tank Type (Check one box only):a.Above-ground b.In-ground 6.Tank Construction Material (Check appropriate box(es) or specify): a.Steel b.Concrete c.Fiberglass d.Plastic e.Other(s) (Please describe below) 7.Tank Capacity (Check one box only): a.Less than 3,000 gallons b.3,000 gallons or more B-I. Compliance Information Section-1 General 101 Do you discharge industrial wastewater to a septic system, leaching field, or cesspool? yes – you must cease discharging and complete a Return to Compliance Plan no 102 Do you discharge industrial wastewater to a storm drain or to the ground without a surface water or groundwater discharge permit? yes – you must cease discharging and complete a Return to Compliance Plan no 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) yes – I have checked with DEP and I am aware of the restrictions that may apply to my facility no 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) yes – I have checked with DEP and I am aware of the restrictions that may apply to my facility no 105 Is this certification for an above-ground holding tank? yes no - skip to question 301 wp56.doc 3/2020 Page 3 of 5 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank Compliance Certification Form (WP 56) DEP Assigned Facility ID or Facility Name B-I. Compliance Information (cont.) Section-2 Above-Ground Holding Tank 201 Is this above-ground holding tank constructed or lined with material compatible with your industrial wastewater? yes no - submit a Return to Compliance Plan 202 Is this above-ground holding tank remotely filled or automatically filled? yes no - skip to question 203 202a Have you provided an appropriate audio and light alarm system for this above-ground holding tank? yes no - submit a Return to Compliance Plan 203 Have you provided appropriate spill containment for this above-ground holding tank? yes no - submit a Return to Compliance Plan 204 Have you provided “Non-Hazardous Industrial Wastewater” labels for this above-ground holding tank? yes no - submit a Return to Compliance Plan 205 Was this above-ground holding tank both installed after November 15, 2002 and fabricated on site? yes no - skip to question 401 205a Was this above-ground holding tank constructed in accordance with engineering plans that were stamped and signed by a Massachusetts Registered Professional Engineer? yes – skip to question 401 no – submit a Return to Compliance Plan and skip to question 401 Section-3 In-Ground Holding Tank 301 Is this in-ground holding tank constructed or lined with material compatible with your industrial wastewater? yes no - submit a Return to Compliance Plan 302 Is the capacity of this in-ground holding tank greater than 500% of the average daily flow? yes no - submit a Return to Compliance Plan 303 Have you provided an appropriate audio and light alarm system for this in-ground holding tank? yes no - submit a Return to Compliance Plan 304 Have you provided “Non-Hazardous Industrial Wastewater” labels or signs for this in-ground holding tank? yes no - submit a Return to Compliance Plan wp56.doc 3/2020 Page 4 of 5 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank Compliance Certification Form (WP 56) DEP Assigned Facility ID or Facility Name B-I. Compliance Information (cont.) 305 Was this in-ground holding tank installed before November 15, 2002? yes no - skip to question 306 305a Was this in-ground holding tank constructed in accordance with engineering plans that were stamped and signed by a Massachusetts Registered Professional Engineer? yes - skip to question 401 no 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? yes - skip to question 401 no - submit a Return to Compliance Plan and skip to question 401 306 Was this in-ground holding tank constructed in accordance with engineering plans that were stamped and signed by a Massachusetts Registered Professional Engineer? yes no - submit a Return to Compliance Plan 307 Have you provided an appropriate secondary containment for this in-ground holding tank? yes no - submit a Return to Compliance Plan Section-4 Record Keeping 401 Do you maintain all holding tank construction and installation records (including all applicable permits) at the facility? yes no - submit a Return to Compliance Plan 402 Do you keep and maintain the appropriate operating records, including wastewater shipment, ultimate destination, and hauler information at the facility? yes no - submit a Return to Compliance Plan wp56.doc 3/2020 Page 5 of 5 Massachusetts Department of Environmental Protection Industrial Wastewater Holding Tank Compliance Certification Form (WP 56) DEP Assigned Facility ID or Facility Name C.Certification Statement (Note: Complete all required Return to Compliance Plan forms before signing this statement) "I, , 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 Date (MM / DD / YYYY) Printed Name Title Source of Signatory Authority (Check appropriate box): 1. If a Corporation: 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)