Industrial Waste And Pretreatment Questionnaire Template Page 2

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Raw Water Sources:
Describe Pretreatment Equipment that will be
Private Wells
_________gallons per day
utilized or installed
?( Interceptors/grease traps/flow
Orem Culinary
_________gallons per day
_____________________
meters/pH monitoring Etc;)
Lindon Culinary
_________gallons per day
_______________________________________
Other: __________
_________gallons per day
_______________________________________
Water Consumed and/or Used in Facility:
Cooling
_________gallons per day
Broiler Feed
_________gallons per day
Process
_________gallons per day
Sanitary
_________gallons per day
In Product
_________gallons per day
OTHER:____________
_________gallons per day
TOTAL:_________ _________gallons per day
Average Volume of Water Loss to:
Evaporation
___________gallons per day
Sanitary Discharge
_________gallons per day Natural Outlet
___________gallons per day
Waste Hauler
_________gallons per day In Product
___________ gallons per day
Other: ______________
_________gallons per day TOTAL
___________gallons per day
Is Process Discharged to the City Sewer System
Is there a Spill Prevention or Slug Management
Yes
No
Plan for this Facility.
Yes
No
If so Please attach a Copy
I am familiar with the information contained in this questionnaire and swear that the information is
true, complete, and accurate. If any of the answers to questions contained in this questionnaire change,
the business will immediately notify the City of Orem of the proposed change(s). Notification does not
constitute approval of the proposed change(s).
____________________________________________________
Date_______________
Signature of Official
If any questions, please contact Orem City Industrial Pretreatment at 801-229-7491.
Leave Questionnaire with Business Licensing or Mail to 1797 West 1000 South Orem UT 84058 Attn:
Industrial Pretreatment Coordinator or Fax to 801-229-7499 : Industrial Pretreatment Coordinator

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