(Person who is thoroughly familiar with operation of the facility and with the facts reported in this questionnaire, who can be contacted if necessary)

*Name

*Title

*Work Phone

*Email

*Facility Mailing Address

*Facility Location

Nature of Business

*Principal Product or Process

Applicable NAICS or SIC Code(s)

*Description of Product or Process

*Hazardous or Significant Chemicals or Materials Stored or Used Onsite

Wastewater Details

*Do you use water for purposes other than sanitary (toilet, shower) use?

Yes

*Do you discharge process wastewater to the public sewer system?

Yes

*Is your facility equipped with a grease trap?

Yes

*Do you treat the wastewater prior to discharge?

Yes

If yes, describe briefly (e.g. pH adjustment, oil separation, etc.)

*Signature

*Date

Confirm

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