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2. Are you completing this survey as part of the Wellington business licensing process?

   1. Yes
   2. No

   Please answer the above question so we can determine what information we might already have from you.

4. Property owner:
6. Property Owner Name*
7. Primary Contact Name*
9. Email Address*
10. Phone Number*
12. Mailing Address*
13. Site Address (if not the same as business address)*
15. Business Owner:
17. Business Name*
18. Primary Contact Name and Title*
20. Phone Number*
21. Email Address*
23. Mailing Address*
25. Facility Operations and Wastewater Information
27. Type of Business*
    -- Select One --CommercialIndustrial
29. Description of business activity (processes, products, services, etc.)*
31. Check all activities which are or will be present at your facility:*

    1. Assembly
    2. Automotive Services
    3. Biotechnology
    4. Dental Office
    5. Dry Cleaning/Laundry
    6. Electroplating
    7. Flammables/Explosives
    8. Food Processing
    9. Food Service/Restaurant

    1. Laboratory
    2. Machine Shop
    3. Manufacturing
    4. Material Transfer/Distribution
    5. Medical Office
    6. Metal Finishing
    7. Office (Non-Medical)
    8. Painting/Stripping/Finishing

    1. Printing
    2. Photo Processing
    3. Research
    4. Retail
    5. Car/Equip. Wash
    6. Wholesale Trade
    7. Warehousing
    8. Other (Specify)
33. If you selected other please specify
34. Total number of employees at this facility:*
36. Hours of operation

    Define shift start-end times and list the average number of employees who work each shift

38. DAY
39. SHIFT 1
40. SHIFT 2
41. SHIFT 3
43. Sunday
48. Monday
53. Tuesday
58. Wednesday
63. Thursday
68. Friday
73. Saturday
78. Is your business a Food Service Establishment (FSE)?*

    1. Yes
    2. No

    (This is any business that makes, prepares and or servers food)

79. If yes, which of the following devices do you have installed?

    1. Grease Interceptor – Interceptors are large capacity tanks normally found outside buildings and may handle larger flows of 50+ gallons per minute.
    2. Grease Trap – Traps are much smaller in size reside inside kitchens and may handle flows in the 10-50 gallon per minute range.
    3. Neither
81. Is your business a Brewery, Distillery, or Winery?*

    1. Yes
    2. No

    NOTE: If the answer to this question is "Yes," please complete the Brewery/Distilling/Winemaking Survey located below this questionnaire.

82. Is your business a Dental Office?*

    1. Yes
    2. No

    NOTE: If the answer to this question is "Yes," please complete the Dental Survey located below this questionnaire.

    
    

84. Is your business an auto repair shop, machine shop, truck/car wash facility or service station? *

    1. Yes
    2. No
85. If yes, does your facility operate a combination sand and oil separator?

    1. Yes
    2. No
87. Indicate the type and number of solutions or materials used in manufacturing, cleaning, or other operations whose containers exhibit hazard warning labels.*

    Attach additional sheets as needed or SDS documents. Amounts used should be listed in gallons/per day

88. Attach additional documentation
90. Description of facilities*

    Kitchen, # of restrooms. laundry facility, chemical storage, etc.

92. Are there any floor drains in the work storage areas at your facility?*

    1. Yes
    2. No
93. If yes, please list location(s)
95. Water use*

    What it is used for and the approximate quantities in gallon/day?

97. Does your facility have any pretreatment devices or processes used for treating wastewater or sludge?*

    Grease interceptor, grease trap, DAF (Dissolved Air Floatation), filtration, pH adjustments, etc.

99. PFAS Survey
101. Emerging Contaminants Survey: Per or polyfluoroalkyl substances (PFAS) also called forever chemicals.

     On July 13, 2020, the Colorado Department of Public Health and Environment adopted Policy 20-1 to protect drinking water from per or polyfluoroalkyl substances (PFAS). These compounds are linked to multiple health effects. 

     The following survey assists staff to meet policy requirements as well as identifying potential programing to assist Wellington businesses with alternatives, chemical storage, or disposal of PFAS compounds.

     Disclaimer: This exercise is for gathering information for future regulatory requirements per CDPHE and EPA. 

103. Please indicate the type(s) of fire suppression system(s) your business uses. Check all that apply:

     1. Handheld (Fire extinguisher style)
     2. Ceiling/Centralized delivery system
     3. Vent or Hood System (nozzles are visible under the hood)
104. Does the label on the fire suppression system contain the letter “B” or AFFF, AR-AFFF, FFFP, AR-FFFP, FP, FPAR? (Fire extinguishers also can be multi labeled, ex. ABC.)

     1. Yes
     2. No
     3. Unknown, not able to determine
106. To the best of your knowledge, has there ever been a fire at your place of business?

     1. Yes
     2. No
     3. Unknown
107. Do you know whether Class B firefighting foam has been stored or spilled from its container, at your place of business?

     1. Yes
     2. No
     3. Unknown
109. Are any of the following products used in your business manufacturing process? Check all that apply:

     1. Chemguard foam
     2. Scotchgard
     3. Tridol
     4. Dry chemicals used for type B fires. (Class B foams are marked with any of the following designations AFFF, AR-AFFF, FFFP, AR-FFFP, FP, FPAR)
     5. ANKOR WETTING AGENT F
     6. Clepo Chrome Mist Suppressant
     7. Fumetrol 140 Mist Suppressant
     8. Benchmark Benchbrite STX
     9. Benchmark CFS

     1. MacDermid Proquel B
     2. MacDermid Macuplex STR
     3. Plating Process Systems PMS-R
     4. Femetrol-140
     5. Brite Guard AF-1 fume control
     6. Gore-Tex
     7. Teflon or Teflon tape coating (including PTFE coatings)
     8. Unknown
     9. None of the above
110. Does your business store, use, manufacture, or machine any of the following agents? Check all that apply:

     1. Electrostatic control agents
     2. Friction control agents
     3. Dirt Repellents
     4. Anti-Adhesives
112. Certificate of Information 
114. The undersigned is a principle or managerial agent for the survey respondent with authority concerning requirements for wastewater discharge from the facility.

     I hereby certify, under penalty of law, that this document and all of its attachments were prepared under my direction or supervision according to a process designed to ensure that qualified personnel properly gather and evaluate the information submitted. The information is, to the best of my knowledge and belief, true, accurate, and complete. 

116. Title*
117. First Name*
118. Last Name*
120. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
122. Electronic Signature*
123. Date*
125. Brewery/Distilling/Winemaking Survey

     1. General Information
127. Business Name*
128. Name of Business Owner*
130. Are the following processes or activities performed at your facility?
132. Brewing:*

     1. Yes
     2. No
133. Distilling:*

     1. Yes
     2. No
134. Winemaking:*

     1. Yes
     2. No
135. Bottling:*

     1. Yes
     2. No
137. Kegging:*

     1. Yes
     2. No
138. Equipment Sanitization:*

     1. Yes
     2. No
139. Product Area Sanitization:*

     1. Yes
     2. No
140. Other: *

     1. Yes
     2. No
142. If you replied "Yes" to "Other" in the question above, please specify below:*
144. Is wastewater generated as a result of this process or activity discharged to the sanitary sewer system?
146. Brewing:*

     1. Yes
     2. No
147. Distilling:*

     1. Yes
     2. No
148. Winemaking:*

     1. Yes
     2. No
149. Bottling:*

     1. Yes
     2. No
151. Kegging:*

     1. Yes
     2. No
152. Equipment Sanitization:*

     1. Yes
     2. No
153. Product Area Sanitization:*

     1. Yes
     2. No
154. Other:*

     1. Yes
     2. No
156. If you replied "Yes" to "Other" in the question above, please specify below:
158. What is the production rate of your operation?
160. Monthly total of Barrels, Kegs, or Gallons:*
161. Yearly total of Barrels, Kegs, or Total Gallons:*
163. Seasonal Average Spring:*
164. Seasonal Average Summer:*
165. Seasonal Average Fall:*
166. Seasonal Average Winter:*
168. On average, how many bad/unconsumable batches are produced each year?*
169. Describe how your bad/unconsumable batches are disposed of: *
171. Do you have documentation of proper grain, yeast, or fermented fruit disposal? (You may be asked to present documentation) *

     1. Yes
     2. No
172. Describe how you dispose of spent grains, yeast, or fermented fruit: *
174. Does this facility currently treat the non-domestic waste streams before discharging to the sanitary sewer system? *

     1. Yes
     2. No
175. If you replied "Yes" to treating non-domestic waste streams before discharge, please describe the process:*
177. Does this facility have plans for future expansions of the brewing, distilling, or fermenting processes? *

     1. Yes
     2. No
178. If yes, please describe:*
180. Is there food service at your location that discharges to the sanitary service? *

     1. Yes
     2. No
181. If yes, please explain: *
183. Is your company currently permitted with Federal, State or Municipal Authorities? *

     1. Yes
     2. No
184. If yes, specify which agency and list the permit number:*
186. Certificate of Information

     1. .
188. The undersigned is a principle or managerial agent for the survey respondent with authority concerning requirements for wastewater discharge from the facility. *

     1. I hereby certify, under penalty of law, that this document and all of its attachments were prepared under my direction or supervision according to a process designed to ensure that qualified personnel properly gather and evaluate the information submitted. The information is, to the best of my knowledge and belief, true, accurate, and complete.
190. Title*
191. First Name*
192. Last Name*
194. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
196. Electronic Signature*
197. Date
199. Dental Survey

     1. General information
201. Name of Business*
202. Name of Business Owner*
204. Name(s) of Additional Owner(s)
206. Contact Information for All Practicing Dentists
208. Name*
209. Phone Number*
210. Email Address*
212. 1. Click for Additional Entry
214. Name
215. Phone Number
216. Email Address
218. 1. Click for Additional Entry
220. Name
221. Phone Number
222. Email Address
224. 1. Click for Additional Entry
226. Name
227. Phone Number
228. Email Address
230. 1. Click for Additional Entry
232. Name
233. Phone Number
234. Email Address
236. Applicability — Please select one of the following:*

     1. This facility is a dental discharger subject to this rule by Federal Regulation 40 CRF Part 441 as it places or removes dental amalgam. Complete Sections A, B, C, and D.
     2. This facility is a dental discharger subject to this rule and (1) it does not place dental amalgam, and (2) it does not remove amalgam except in limited emergency or unplanned, unanticipated circumstances. Complete Section D only.
238. Also select if applicable: Transfer of Ownership (§ 441.50(a)(4))

     1. This facility is a dental discharger subject to this rule (40CRF Part 441) and has previously submitted a Dental Survey. This facility is submitting a new One Time Compliance Report because of a transfer of ownership as required by Federal Regulation 441.50(a)(4).
240. Section A

     1. Description of Facility
242. Total Number of Chairs*
243. Number of chairs at which amalgam may be present in resulting wastewater (chairs where amalgam may be placed or removed)*
245. Descriptions of any amalgam separator(s) or equivalent devices(s) currently operated*
246. Did this facility discharge amalgam process wastewater prior to July 14, 2017, under any ownership? *

     1. Yes
     2. No
248. Section B

     1. Description of Amalgam Separator or Equivalent Device
250. 1. The dental facility has installed one or more ISO 11143 (or ANSI/ADA 108-209) compliant amalgam separators (or equivalent devices) that captures all amalgam placement or removal may occur
251. Chairs
253. 1. The dental facility prior to June 14, 2017, installed one or more existing amalgam separators that do not meet the requirements of Reg 441.30(a)(1)(i) and (ii) at the following number of chairs at which amalgam placement or removal occur: I understand that such separators must be replaced with one or more amalgam separators (or equivalent devices) that meet the requirements of Regulation 441.30(a)(1) or 441.30(a)(2), after their useful life has ended, and no later than June 14, 2027, whichever
254. Chairs
256. Make
257. Model
258. Year of Installation
260. 1. Click for Additional Entry
262. Make
263. Model
264. Year of Installation
266. 1. Click for Additional Entry
268. Make
269. Model
270. Year of Installation
272. 1. Click for Additional Entry
274. Make
275. Model
276. Year of Installation
278. 1. Click for Additional Entry
280. Make
281. Model
282. Year of Installation
284. 1. My facility operates an equivalent device.
286. Make
287. Model
288. Year of Installation
289. Average removal efficiency of equivalent device, as determined per Reg. 441.30(a)(2)i- iii.
291. 1. Click for Additional Entry
293. Make
294. Model
295. Year of Installation
296. Average removal efficiency of equivalent device, as determined per Reg. 441.30(a)(2)i- iii.
298. 1. Click for Additional Entry
300. Make
301. Model
302. Year of Installation
303. Average removal efficiency of equivalent device, as determined per Reg. 441.30(a)(2)i- iii.
305. 1. Click for Additional Entry
307. Make
308. Model
309. Year of Installation
310. Average removal efficiency of equivalent device, as determined per Reg. 441.30(a)(2)i- iii.
312. 1. Click for Additional Entry
314. Make
315. Model
316. Year of Installation
317. Average removal efficiency of equivalent device, as determined per Reg. 441.30(a)(2)i- iii.
319. Section C

     1. Design, Operation and Maintenance of Amalgam Separator/Equivalent Device
321. 1. I certify that the amalgam separator (or equivalent device) is designed and will be operated and maintained to meet the requirements in Regulation 441.30 or 441.40.
323. Is a third-party service provider under contract with this facility to ensure proper operation and maintenance in accordance with § 441.30 or § 441.40?*

     1. Yes
     2. No
325. If Yes, List name of the third-party service provider (e.g., Company Name) that maintains the amalgam separator or equivalent device (if applicable):
326. If No, provide a description of the practices employed by the facility to ensure proper operation and maintenance in accordance with § 441.30 or § 441.40:
328. Section D

     1. Certification Statement
330. The undersigned is a principle or managerial agent for the survey respondent with authority concerning requirements for wastewater discharge from the facility. *

     1. I hereby certify, under penalty of law, that this document and all of its attachments were prepared under my direction or supervision according to a process designed to ensure that qualified personnel properly gather and evaluate the information submitted. The information is, to the best of my knowledge and belief, true, accurate, and complete.
332. Title*
333. First Name*
334. Last Name*
336. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
338. Electronic Signature*
339. Date*
341. Authorized Representative

     1. I am an Authorized Representative (AR)
342. AR Phone Number
343. AR Email Address
Leave This Blank:


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

     This field is not part of the form submission.

347. Submit

* indicates a required field