Sacramento Regional County Sanitation District
Instructions
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Please, print legibly or type
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Complete all information that applies to
your business
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Optional
information items are not required but may allow us to waive
follow-up information requests and/or inspections
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1a. |
Company Name: |
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Address: |
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City: |
State: |
Zip: |
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Mailing Address (if different): |
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Contact Person: |
Telephone: |
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1b. |
Is this a home-based
business? |
Yes
or No |
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2. |
Description of Business: Please
be detailed (list types of products/ services/ processes) |
3. Optional
- North American Industry Classification System (NAICS) code number:
______________ (or SIC code: _______)
(If you do not know your NAICS code you may call the Industrial
Waste Section at 875-6470 and we can look it up for you.)
4. Number
of full-time employees at this location:
_____________________
5. Business
hours: _____________________
6. Excluding rest rooms, lunchroom, and
landscape watering, do you use water in any of your business activities? Yes No
7. Describe business activities
(processes) which generate wastewater at this location or at the job site you
serve (state ‘none’, if none):
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(Continued
on other side)
8.
a.
Excluding sanitary wastewater, approximate amount of process wastewater
discharged to the sewer per day (state ‘none’, if none):
b.
If wastewater is not discharged to the
sewer, where is it disposed?
9. List any substances, materials, or chemicals
that may be present in your wastewater (state ‘none’, if none):
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(You may attach additional sheets if
necessary.)
10. Do
you have any of the following? (Circle one)
Sump Oil/Sand/Water Interceptor Pretreatment Unit
______________
Grease Trap (inside bldg) Grease
Interceptor (outside bldg) None
11. Do you conduct mobile pressure
washing*? Yes No
*Mobile Pressure Washing is generally defined as any activity that uses powered cleaning equipment and water to remove any substance from outside surfaces of customers’ structures. Mobile Pressure Washing includes, but is not limited to: transportation-related washing (vehicle and lot washing, etc.), structural cleaning (sidewalks, plazas, service stations, buildings, etc.), food-related cleaning (restaurant and grocery alleys, kitchen grease fixtures, lunch wagons, etc.).
12. Do you (or a contractor) discharge or
plan to discharge pressure washing* wastewater to the sewer system? Yes No
I certify that the information
furnished herein is true and correct to the best of my knowledge. (Must
be signed by authorized representative of the facility.)
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Signature: |
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Date: |
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Name (type or print): |
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Title: |
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Make a copy for your records and send or fax completed
questionnaire to:
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Industrial Waste Section |
Phone: (916) 875-6470 |
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Water Quality Division |
Fax: (916) 875-6374 |
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