SACRAMENTO REGIONAL COUNTY SANITATION DISTRICT
Please print legibly
and complete all sections.
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SECTION 1 |
Business name: |
Business address: |
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Owner name: |
Mailing address: |
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Contact person: |
Business phone: |
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SECTION 2 |
The business above conducts or engages in surface cleaning/pressure washing activities as follows: List all types of cleaning performed and the cleaning procedure (attach additional sheets if necessary) |
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Type Of Surface To Be Cleaned |
Cleaning Procedure |
Cleaning Products Used |
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Circle wastewater disposal option(s) used in your
pressure washing practices: 1. Landscape at business location 2. Parking lot at business 3. Storm drain at business 4. Sanitary sewer at business 5. County hauled waste disposal facility 6. Private treatment company/facility 7. Hauled back to your business location (Note whether put into sewer, storm drain or other: _____________________) |
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Average number of gallons of wastewater disposed to the sanitary sewer cleanout or interior drain per day: __________ gallons per day to sewer |
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What temperature water do you use (please circle)? HOT COLD BOTH |
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Do you plug or block storm drains while operating pressure-washing equipment? YES NO If so, what materials do you use? |
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List any type of pretreatment used prior to discharge of wastewater to the sewer (example: filters, chemicals, etc.): |
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SECTION 3 |
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision and in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person(s) who manage the system, or those directly responsible for gathering the information, the information submitted is, to the best of my knowledge, 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. Signature: ______________________________________ Date: _______________________________ Name (type or print): ______________________________ Title: ______________________________ |
Make a copy of this application for your records and return completed original to:
Sacramento Regional County Sanitation District
Industrial Waste Section Phone: 916-875-6470
9660 Ecology Lane Fax: 916-875-6374