Name Of Industry:   						   IUP #  		
Address Of Industry:   							       IUP Expiration Date:

Industry Representatives:						Title

POTW Representatives:						Title

Date Of Inspection:   				   Time Of Inspection:   			  am/pm
Purpose of Inspection:  Annual   		   Other (Describe)   					
POTW to which IU discharges   					NPDES #    			
Is SIU currently in SNC?   		   If yes, for what?   					

PART I - INITIAL INTERVIEW
Has anything changed since the last inspection or IUP application in the following:
						COMMENTS
Product				YES / NO   							
Raw materials used		YES / NO   							
Manufacturing processes		YES / NO   							
       Categorical, if applicable	YES / NO   							
Production rate			YES / NO   							
Number of employees		YES / NO   							
Number of shifts		YES / NO   							

Comments:

PART II - PLANT TOUR - Visit all areas where wastewater is generated or where there are drains to the POTW.
Plant Tour Section A - PRODUCTION AND STORAGE AREAS

1.  Are there floor drains in the production area?    YES / NO    Where do they go?   			
												
2.  Are production areas diked, contained, or otherwise constructed in such a way as to prevent harm to the WWTP, especially from spills or slugs?    YES / NO   Comments:   					
												
3.  Are there floor drains in the storage area?    YES / NO    Where do they go?   			
												
4.  Are storage tanks and areas diked, contained, or otherwise constructed in such a way as to prevent harm to the WWTP, especially from spills or slugs?    YES / NO   Comments:   				
												
5.  Are process and storage tanks and pipes labeled?    YES / NO
6.  How are off-spec raw materials, and products disposed of?   					
												
7.  When is the production area cleaned?   								
8.  Is the wastewater from cleaning the production area discharged to the POTW?    YES / NO
9.  What non-process wastewaters are discharged to POTW?   						

Comments:

PART II - Plant Tour Section B - PRETREATMENT SYSTEM
Ask the operator to describe pretreatment system. 
1.  Does operator seem knowledgable about the system?    YES / NO   Comments:   			
												
2.  Are all units operational?    YES / NO
3.  How often does operator/maintenance person check system?   					
4.  Is there an operator for each shift?    YES / NO
5.  How and when is sludge disposed of?   								
												
6.  Is there a schedule for preventative maintenance?    YES / NO

Comments:

PART II - Plant Tour Section C - SAMPLING POINT(S) AND FLOW MEASUREMENT
(Collect a sample if desired.)
1.  Does an outside lab complete sampling?    YES / NO    If yes, name of lab.   			
2.  If industry completes sampling, ask the industry representative to describe sampling procedures.    Comments:   											
3.  Is flow measurement equipment operational?    YES / NO    Comments:   				
												
4.  Is there a calibration log for the flow meter?    YES / NO    Comments:   				

Comments:

PART III - EXIT INTERVIEW
Review monitoring records and other SIU records required by IUP.
1.  Are files well organized?  YES / NO  Comments:   						
2.  Are sample collection / chain-of-custody forms filled out properly?    YES / NO    Comments:   	
												
3.  Do results in files agree with reports sent to POTW?  YES / NO  Comments:   			
												
4.  Who has authority to shut down production should a spill or slug discharge occur?   			
												
5.  How does SIU inform employees of whom to call at POTW in case of spill/slug?   			
												
If slug/spill plan is already required by POTW, review procedures.
6.  Is SIU implementing slug/spill plan?  YES / NO  Comments:   					

Comments:
INSPECTION RESULTS
Slug/Spill Control Plan Needed?    YES / NO
Comments, Required Or Recommended Actions:   							

												
Signature Of Inspector(s)   					  Date: 		
				   					  Date: