Form Center

2. Name of Business*
4. Business Address*
6. Official Contact Name*
7. Phone Number*
9. Type of Business*
11. Gallons of water used per day*
12. Hours of Operation*
14. Does your business do or have any of the following:
16. Laundry facilities or service?*

    1. Yes

    1. No
17. Is phosphorus detergent used?*

    1. Yes

    1. No
19. Develop photographic materials?*

    1. Yes

    1. No
20. How are chemicals disposed of?
22. Serve or prepare food?*

    1. Yes

    1. No
23. What type of food?
24. How is waste food disposed of?
26. Handle hazardous waste?*

    1. Yes

    1. No
27. How is waste disposed of?
29. Deep fry food?*

    1. Yes

    1. No
30. How is oil disposed of?
32. Clean oily/greasy parts?*

    1. Yes

    1. No
33. How is oil waste/solvent solution disposed of?
35. Process/manufacture dairy foods?*

    1. Yes

    1. No
36. What type of product?
38. Vehicle wash bays?*

    1. Yes

    1. No
39. How often is grit separator cleaned?
41. Grease/oil waste?*

    1. Yes

    1. No
42. How is waste disposed of?
44. Grease trap?*

    1. Yes

    1. No
45. How often is it cleaned out?
47. Industrial spray painting?*

    1. Yes

    1. No
48. How is paint disposed of?
50. Oil water separators?*

    1. Yes

    1. No
51. How is oil waste disposed of?
53. Phosphate rinse system?*

    1. Yes

    1. No
54. How is waste phosphate washwater disposed of?
56. Change vehicle fluids?*

    1. Yes

    1. No
57. How are waste fluids disposed of?
59. Electroplate metals/parts/circuitboards?*

    1. Yes

    1. No
60. Basement sump pump?*

    1. Yes

    1. No
62. Electronic Signature Agreement*

    I certify, under penalty of law, that I have personally examined and am familiar with the above information, and based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
64. Electronic Signature
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66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

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