Revised pollution prevention plans for inorganic chloramines and chlorinated wastewater effluents: schedule 1

Schedule 1: Declaration That a Pollution Prevention Plan Has Been Prepared and Is Being Implemented - Inorganic Chloramines and Chlorinated Wastewater Effluents (Subsection 58(1) of CEPA 1999)

NOTE: Please contact the National Office of Pollution Prevention for more information about electronic reporting or the filing of paper forms.

Notice Reference Code: P2CLMWWE

• 1.0 Information on the Person or Class of Persons Subject to the Notice
• 2.0 Use of Plans Prepared or Implemented for Another Purpose
• 3.0 Substance and Activity
• 4.0 Baseline Information Prior to Implementation of the Pollution Prevention (P2) Plan
  • 4.1 - 4.4 No information required for Parts 4.1 to 4.4 of this Declaration
  • 4.5 Additional Baseline Information
• 5.0 Anticipated Actions and Results
  • 5.1 Anticipated Action(s)
  • 5.2 No information required for Part 5.2
  • 5.3 Detailed Anticipated Results Information
• 6.0 Monitoring and Reporting
• 7.0 Risk Management Objective
• 8.0 Factors to Consider
• 9.0 Certification

Please refer to the instruction booklet "Instructions for Completing the Schedules of the Canada Gazette Notice Requiring the Preparation and Implementation of Pollution Prevention Plans for Inorganic Chloramines and Chlorinated Wastewater Effluents" for guidance on how to complete this Declaration. Electronic copies of the Notice, and the instructions for completing the declarations (Schedules 1 to 5), are available from the Pollution Prevention website or can be requested by telephone at 819-994-0186, by fax at 819-953-7970, or by email; CEPAP2Plans@ec.gc.ca.

Is this an amendment to a Declaration previously submitted? Yes   No

If yes, complete Parts 1.0 and 9.0 and any other Parts of this Declaration where previously reported information has become false or misleading. Previously reported information that is unchanged need not be resubmitted.

1.0 Information on the Person or Class of Persons Subject to the Notice

Name of the Person or Class of Persons Subject to the Notice: ____________
Facility Name: ____________
Street Address of Facility: ____________
City: ____________
Province/Territory: ____________
Postal Code: ____________
Telephone number: (with area code) ____________
e-mail (if available): ____________

If different from Street Address
Mailing Address of Facility: ____________
City: ____________
Province/Territory: ____________
Postal Code: ____________

National Pollutant Release Inventory ID (if no ID, leave blank): ____________
6-digit North American Industry Classification System (NAICS) Code: 221320

Facility Technical Contact: ____________
e-mail (if available): ____________
Telephone Number: (with area code) ____________
Fax Number (if available): (with area code) ____________

2.0 Use of Plans Prepared or Implemented for Another Purpose

Is the pollution prevention plan used to fulfill the obligations of the Notice:

3.0 Substance and Activity

Substance and Activity for which information is required.

Inorganic Chloramines and Chlorinated Wastewater Effluents: Persons identified in section 2 of the Notice who are required to prepare and implement a pollution prevention plan for inorganic chloramines and chlorinated wastewater effluents for the use of chlorine or chlorine compounds in wastewater systems and the release of chlorinated wastewater effluent to surface water.

4.0 Baseline Information Prior to Implementation of the Pollution Prevention (P2) Plan

This Declaration requires reporting of data from the Preparation Year, either 2004 or 2005 (January 1 to December 31).

If the person(s) subject to the Notice has been granted a time extension to prepare a plan that requires reporting for a year other than 2004 or 2005, all references to 2004 or 2005 in this Declaration are considered to represent the new Preparation Year for which the person(s) is required to report.

If applicable, indicate the new Preparation Year for which the person(s) is(are) reporting: ____________

4.1 - 4.4 No information required for Parts 4.1 to 4.4 of this Declaration

4.5 Additional Baseline Information

4.5.1 Wastewater System Information

This section requires reporting of information on the wastewater system in place for 2004 or 2005. Check whichever of the following boxes apply to your system. Note that more than one box in each section may apply .

No Treatment
 No Treatment (e.g. collection system with release to surface water)

Preliminary Treatment
 None
Grit removal
Screening
 Skimming
 Other (describe) ______________

Physical / Chemical Primary Treatment
 None
 Primary sedimentation/clarification
 Chemical flocculation
 Other (describe) ______________

Biological or Secondary Treatment - Mechanical Systems (some systems may have more than one kind of treatment)
 None
 Conventional Activated Sludge
 Extended Aeration Activated Sludge
 Pure Oxygen Activated Sludge
 Other Activated Sludge
 Oxidation Ditch
 Trickling filter
 Rotating Biological Contactor (RBC)
 Sequencing Batch Reactor (SBR)
 Other (describe) ______________

Biological or Secondary Treatment - Lagoons or Waste Stabilization Ponds (WSPs) (some systems may have more than one kind of treatment)
 None
 Aerated
 Aerobic
 Facultative
 Storage Ponds
 Anaerobic
 Other (describe) ______________

Effluent Disinfection
 None
 Disinfection: All Year
 Disinfection: Seasonal or intermittent. If seasonal, specify the period of disinfection (which months) or if it is intermittent, specify the frequency: ____________
 Chlorination only
 Chlorination and dechlorination
 Ozone
 Ultraviolet irradiation
 Other (describe) ______________

Other Information
Name of the surface water body that effluent is released to ______________
Freshwater
Saltwater

4.5.2 Releases to Surface Water

4.5.2.1 Inorganic Chloramines and Chlorinated Wastewater Effluents

Report in the table below the average flow of wastewater effluent and the maximum Total Residual Chlorine (TRC) concentrations. The average monthly flow should be determined on the basis of daily flow measurements. The maximum total residual chlorine concentration should be determined on the basis of representative sampling.

5.0 Anticipated Actions and Results

5.1 Anticipated Action(s)

The following section (Parts 5.1.1. through 5.1.6) must be completed separately for each anticipated action in the pollution prevention plan, i.e., this section will be completed as many times as there are anticipated actions to report.

In Part 5.1.1, describe for the activity identified in Part 3.0 of this Declaration, the anticipated action to be taken in implementing the Pollution Prevention Plan. In Parts 5.1.2 and 5.1.3, for each anticipated action, identify the type of pollution prevention method(s) or environmental protection method(s), by selecting from the list of options provided below. In Part 5.1.4, report, where possible, the corresponding change to the maximum concentration of total residual chlorine measured in the effluent released to surface water, anticipated to be achieved from implementation of that action, in mg/L. Refer to the instructions for specific information on how to report. Indicate a decrease with a negative sign ("-") and an increase with a positive sign ("+") in front of the reported change. Note that predicting a quantitative change as a result of some anticipated actions, such as training, may not be possible. Finally, in Part 5.1.6, identify the planned completion date for the anticipated action.

5.1.1 Anticipated Action: ______________________________________________________________________

5.1.2 Type of Pollution Prevention Method(s):

 Equipment or process modifications
On-site reuse, recycling or recovery
Spill and leak prevention
Good operating practices or training
Other: _________________________________________

5.1.3 Other Type of Environmental Protection Method(s):

 Energy recovery
Pollution control
Off-site recycling
Disposal
Waste treatment
Other: _________________________________________

5.1.4 Anticipated Change(s):_____________________________________________

5.1.5 No information required for Part 5.1.5 of this Declaration.

5.1.6 Planned Completion Date (year/month/day):______________________________________

This ends the section (Parts 5.1.1. through 5.1.6) that must be completed separately for each anticipated action in the P2 plan.

5.2 No information required for Part 5.2

5.3 Detailed Anticipated Results Information

Total Anticipated Results for Inorganic Chloramines and Chlorinated Wastewater Effluents

The table below summarizes, for the activity identified in Part 3.0 of this Declaration, the anticipated change to the maximum concentration of total residual chlorine (TRC) in the effluent released to surface water, in mg/L and as a percentage relative to the Preparation Year.

Report the total changes anticipated to be achieved from implementing all of the anticipated actions described in Part 5.1 of this Declaration.

* Indicate a decrease with a negative sign ("-") and an increase with a positive sign ("+") in front of the reported change.

6.0 Monitoring and Reporting

For the activity identified in Part 3.0 of this Declaration, describe anticipated monitoring and reporting that will be used to track progress in implementing the Pollution Prevention Plan.

___________________________________________________________

7.0 Risk Management Objective

For the activity identified in Part 3.0 of this Declaration, describe how the Pollution Prevention Plan outlined in this Declaration meets the risk management objective identified in subsection 4(3) of the Notice. If this plan does not meet the risk management objective, explain why.

___________________________________________________________

8.0 Factors to Consider

Describe what was done by the person or class of persons subject to the Notice to take into account the other "factors to consider" in subsections 4.2 and 4.5 of the Notice, except those factors for which a waiver has been granted by the Minister.

___________________________________________________________

9.0 Certification

I hereby certify that a Pollution Prevention Plan has been prepared and is being implemented for inorganic chloramines and chlorinated wastewater effluents and that the information provided in this Declaration is true, accurate and complete.

___________________________________________________________
Signature of the Person(s) subject to the Notice or Duly Authorized Representative

___________________________________________________________
Date

Name:
___________________________________________________________
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Title/Position:
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