Industrial Waste And Pretreatment Questionnaire Template
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2Industrial Waste and Pretreatment Questionnaire
Public Works Department Industrial Pretreatment * 1797 West 1000 South. *Orem UT 84058* 801-229-7491
Are you constructing only a building shell or requesting a Subdivision Plat at this time? □ Yes □ No
● if you checked the “No” box, please fill out both Sections 1 and 2 below.
● if you checked the “Yes” box, please fill out Section 1 only. However, this questionnaire shall be completed
entirely in conjunction with the building permit at the time the interior of the shell is finished, and prior to
occupancy.
Business Name:
Phone:
Business Address:
Mailing Address:
Signing Official(s): Print or Type Name(s) & Title
Contact Official(s): Print or Type Name(s) & Title
1.
1.
2.
2.
Phone #
Phone #
Standard Industrial Classification Code __________
Material Safety Data Sheets (MSDS) shall be filed Before
Business Operations
Briefly Describe Manufacturing or Service Activities:
List Principal Raw Materials Used:
__________________________________________
____________________________________
__________________________________________
_______________________________________
__________________________________________
_______________________________________
__________________________________________
______________________________________
__________________________________________
______________________________________
# of employees____& If Day Care # of students_____
If Nursing or Care Facility # of Residents _______
List Types of Chemicals Used
List Principal Products or Services of the
(Including all Solvents, Soaps, Detergents Etc;)
Business
___________________________________________
_______________________________________
__________________________________________
_______________________________________
___________________________________________
_______________________________________
___________________________________________
_______________________________________
_______________________________________
Type of Discharge
Batch
Continuous
Is Production Seasonal?
Yes
No
(Batch Discharge is a controlled release of discharge)
IF Yes Explain:___________________________
If Batch, How Many Gallons Discharged per Batch
_______________________________________
________________ # of Batches in 24 hrs _________
_______________________________________
_______________________________________
Avg. Continuous Discharge in gallons per day_______
Known
Estimated
Please turn page over and complete the
questionnaire
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