Commercial Wastewater User Questionnaire

Name of Business*

Site Address*

City*

State*

Zip*

Contact Name*

Provide the name of the on site responsible representative.

Contact Title*

Contact Phone*

Contact Email*

Manufacturing or Service Activity at the Facility*

Examples: Sales, warehousing, assembly, manufacturing, fabricating, welding, anodizing, plating, etc.

SIC Code*

can be found at https://www.osha.gov/pls/imis/sicsearch.html

Chemicals on premises?

This refers to non household chemicals not commercially available.

Select

List of Chemicals on premises

Hauled Waste?

Is there any waste, other than office or kitchen waste, that is hauled from the premises?

Select

List of wastes hauled

Oil, Grease, Coolant, or other liquids?

Is there any of these liquids stored & hauled off from the premises?

Select

List of liquids stored and hauled off

Send wastewater to public sewer?

Is there any activity that sends wastewater to the sewer, other than restroom or kitchen?

Select

List of wastewaters

Wastewater Tanks or Pits?

Select

List of tanks and pits

Location of Floor Drains

Sample Well?

Does the facility have a sample well?

Select

Sample Well Location

Interceptor or Separator?

Do you have a grease trap or oil sand separator, etc?

Select

Interceptor Type

Interceptor Location

Chemical Inventory

List of Chemicals on Premises

File Attachments

Provide a list of chemicals on premises, where they are stored, what amounts, and whether they have containment.

Drag and drop files here or

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