Wastewater Discharge Survey Company Name* Facility Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility Location Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Phone Number*Facility Discharges Wastewater to:* Sewer System Septic System Standard Industrial Classification (SIC) Number:* SIC can be found at www.osha.govHours of Operation* Type of Business*Auto Repair ShopBreweryCar WashDental OfficeFuneral HomeGas StationHealthcare FacilityHospitalHotelIndustrial Beverage FacilityIndustrial Food FacilityLaundry FacilityManufacturing FacilityOther (please specify below)Physician's OfficeRestaurantSchoolPlease Specify "Other" Type of Business If you selected "Other" from the drop-down list above, please specify your type of business now.From the list below, please select all that apply to your facility:* Commercials washers used Deep fryer used Food service carry out Food service dine in Grill used Grease removal device installed Hazardous waste Laundering chemicals used Oil, sand, or grit removal device installed Oil, antifreeze, or other automotive fluid stored on-site Paint or inks stored or used on-site Photo development on-site Vehicles washed on-site X-ray development on-site Estimated Water Use Per Day (In Gallons):* Name of Authorizing Representative* First Last Title/Position of Authorizing Representative* Electronic Signature* "By entering my name and title in the field above, I hereby sign and certify under penalty of law that this document and its contents were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted hereto. Based on my inquiry of the person(s) who manage the system, or those persons directly responsible for gathering the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations."
