13b. HVAC Waste Water Discharge Request Form.pdf

20212rc

Kirtland AFB HVAC Wastewater Discharge Request Form Requestor: Complete Blocks A and B and submit to 377 MSG/CEIEC not less than 7 business days prior to proposed discharge date. 377 MSG/CEIEC will review and return written approval or denial in Block C. All HVAC discharge dates must be coordinated to ensure compliance with Kirtland AFB Discharge Permit. Requestor must then complete Block D and submit to 377 MSG/CEIEC or request an extension in writing/email not later than 7 business days after date in Block C. Failure to complete discharge on approved discharge date and return completed form may result in notice of violation and monetary fine (to be paid by contractor).

A – Contact Information (to be completed by requestor) Requesting Organization: Contact Name:

Contact Phone Number:

Date of request: Contact email:

B – Project Information (to be completed by requestor) KAFB Building #: System Capacity

(gal):

Proposed discharge (gal):

Description of wastewater proposed for discharge:

Reason for proposed discharge:

Proposed Discharge Date: Proposed Discharge Location:

C – Approval/Denial (to be completed by 377 MSG/CEIEC) Proposed discharge is approved to occur on

________________. Any change of discharge date must be approved by 377 MSG/CEIE in advance.

Proposed discharge is denied

Approving Official: Signature/Date:

Comments:

D – Action Taken (to be completed by requestor) Approved Discharges ONLY Denied Discharges ONLY

Date of Discharge: Date Shipped for Disposal:

Start & End Time of Discharge:

Actual Amount of Discharge: Disposal Facility:

Actual Location of Discharge: Date Shipping Paperwork Provided to 377 MSG/CEIEC:

Technician Name (print and sign):