DS14 Halifax Water Pollution Prevention Abbreviated Discharger Information Report - Form 1 Required fields are marked with an asterisk (*) The completion of this form by all dischargers of wastewater systems is required under the Schedule of Rates, Rules & Regulations for Water, Wastewater, and Stormwater Services. Business Name This field is required. Customer Name This field is required. Enter business address: Unit / Suite Street Name and Type This field is required. City This field is required. Province This field is required. - Select -British ColumbiaAlbertaManitobaSaskatchewanOntarioQuebecNew BrunswickNewfoundland and LabradorNova ScotiaPrince Edward IslandNorthwest TerritoriesNunavutYukon Postal Code This field is required. Is the mailing address the same as the business address? Yes No Please enter your mailing address Unit / Suite Street Name and Type City Province - Select -British ColumbiaAlbertaYukonSaskatchewanNorthwest TerritoriesManitobaNunavutOntarioQuebecNew BrunswickNova ScotiaPrince Edward IslandNewfoundland and Labrador Postal Code Email This field is required. Telephone This field is required. Fax Permit/Application Number What are your principal products produced or services provided: This field is required. Provide a brief description of your manufacturing or service activities: This field is required. ARE THERE ANY OF THE FOLLOWING WASTEWATER DISCHARGES? Process Wastewater Yes No Non-Contact Cooling Water Yes No Other Sources of Wastewater (non-domestic) Yes No If you answered yes to the last question, please provide a brief description below (if not, skip) Location of Process Units? Indoor Outdoor Outdoor (covered) Not Applicable Storage of Raw Materials? Indoor Outdoor Outdoor (covered) Not Applicable Storage of Intermediate Products? Indoor Outdoor Outdoor (covered) Not Applicable Storage of Final Products? Indoor Outdoor Outdoor (covered) Not Applicable Please list the type of chemicals or other waste materials that are discharged to the wastewater system. This field is required. IS YOUR WASTEWATER SUBJECT TO ANY TYPE OF TREATMENT BEFORE DISCHARGE? IF YES, YOU ARE REQUIRED TO ALSO FILL OUT THE DETAILED DISCHARGER INFORMATION REPORT (FORM DS15) Grease Interceptor (CAN/CSA B-481.2) Yes No Vehicle and Equipment Service Oil and Grease Interceptor Yes No Sediment Interceptor Yes No Dental Waste Amalgam Seperator Yes No Other Pre-Treatment (please describe) DOES THE SITE HAVE ANY OF THE FOLLOWING PROGRAMS IN PLACE TO ADDRESS DISCHARGES TO THE WASTEWATER SYSTEM? Pollution Prevention Yes No Best Management Practices Yes No Environmental Management System Yes No Additional Programs/Practices Yes No Name This field is required. Title Email This field is required. Telephone This field is required. I verify that all information provided is accurate and complete. This field is required. If you have any questions or concerns regarding this form please contact our Customer Care Centre.
