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® CITY OF S.JCKTON <br /> MUNICIPAL UTILITIES DEPARTMENT <br /> REGIONAL WASTEWATER CONTROL FACILITY Septic Tank Truck <br /> 2500 NAVY DRIVE <br /> STOCKTON, CALIFORNIA 95206 Special Application/Permit <br /> (209) 944-8750 <br /> FAX: (209) 944-8708 For Wastewater Discharge <br /> PART C - DISCHARGE INFORMATION <br /> Substances Proposed to be Discharged — Give common and technical names of any materials proposed to be discharged. Briefly <br /> describe the physical and chemical properties of each substance and product. Include Laboratory Analysis and Material Safety Data Sheets. <br /> NAME DESCRIPTION QUANTITY Gallons <br /> Discharge Information — Number of batch discharges: per month/day (circle one) <br /> Time of batch discharges: at <br /> (Days of Week) (Hours of Day) <br /> Average quantity per batch: gallons. <br /> Comments: <br /> Wastewater Consitutents— Indicate if any of the following constituents, characteristics or substances is or can be present(X) in your <br /> wastewater discharge. <br /> CODE CONSTITUENTS CODE CONSTITUENTS CODE CONSTITUENTS <br /> ALGC Algicides* FORMA Formaldehyde RAD Radioactivity' <br /> AL Aluminum HC Hydrocarbons` SE Selenium <br /> NH3N Ammonia I- Iodide AG Silver <br /> SB Antimony FE Iron NA Sodium <br /> AS Arsenic PB Lead SOLV Solvents' <br /> BA Barium MG Magnesium SO4= Sulfate <br /> BE Beryllium MN Manganese S=T Sulfide <br /> B Boron HG Mercury S03= Sulfite <br /> BR- Bromide MO Molybdenum MBAS Surfactants MBAS <br /> CD Cadmium NI Nickel TEMP Temperature <br /> CA Calcium O&G M Oil & Grease (Min. Orig.) <br /> CL2 Chlorine O&G T Oil & Grease Total TI Titanium <br /> CL- Chloride PESTC Pesticides' SN Tin <br /> CR Chromium PH pH Increase + V Vanadium <br /> CO Cobalt PH pH Decrease (-) TVA Volatile Acids <br /> CU <br /> Copper PHENL Phenols ZN Zinc <br /> CN Cyanide P Phosphorus N Total Nitrogen <br /> F- Fluoride K Potassium C Cresols` <br /> 'Identify the Chemical Compounds or Elements (Include Laboratory Analysis) <br /> Comments <br /> Other Liquid, Solid or Semi-Solid Wastes — List the type and volume of liquid waste removed from the premises. <br /> DESCRIPTION VOLUME al/mo REMOVED BY name and address DISPOSAL SITE <br />