Page 1 of 3 Please complete all required fields! Please complete the following nomination form. An inspection form and documentation list will be sent to each plant nominated prior to the inspection date. If you would like a copy of these forms, please contact Roman Rodriguez III. Nomination forms will not be accepted if received after July 15. Fields marked with an (*) are required. Award Type(*) Plant Operations & Maintenance AwardBiosolids Award Invalid Input Facility Name(*) Invalid Input Facility Address(*) Invalid Input City(*) Invalid Input State(*) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa KansasKentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Invalid Input Zip(*) Invalid Input Name of Facility Representative(*) Invalid Input Representative Phone(*) Invalid Input Class Description Design PE 1a Lagoon < 150,000 gpd 1b Lagoon > 150,000 gpd 2 Mechanical < 350,000 gpd 3 Mechanical 0.35 to 1.0 mgd 4 Mechanical 1.0 to 3.0 mgd 5 Mechanical > 3.0 mgd 6a Industrial Direct Discharge All 6b Industrial Indirect Discharge All Plant Award Class(*) Please Select1a1b23456a6b Invalid Input Design Flow(*) Invalid Input Number of NPDES violations this year(*) Invalid Input Number of POTW pretreatment violations (indirect discharger)(*) Invalid Input Reasons why you think this facility is deserving of the award(*) Invalid Input By submitting this form, I certify that the above information, provided by me, is true and correct. Full Name(*) Invalid Input Phone(*) Invalid Input Email(*) Invalid Input (*) Invalid Input
