Wastewater Discharge Questionnaire for Non-Residential Establishments

 
1 Start 2 Complete
SECTION A – GENERAL INFORMATION

Facility Address

Mailing Address

Signing Official

Local Company Representative

Person Completing Questionnaire:

List all Standard Industrial Classification Number(s) (SIC Code) for your facility, if known, in descending order
Information:*
SECTION B – WATER USE
SOURCE(S)
Percent of Total Use

TOTAL

SECTION C – FACILITY WASTE AND OPERATIONAL INFORMATION
(Part C refers to operation located at the facility address in Section A.1)

Please provide an estimate of the disposition of water used from all sources during the past year.

Portion of Wastes Discharged to Loudoun Water Sanitary Sewer
Percent of Total Use
Portion of Wastes NOT Discharged to Loudoun Water Sanitary Sewer
Percent of Total Use

Address

Please check any of the toxic pollutants listed below which you know are being used at your facility in manufacturing the product(s) or is a by-product which may be discharged. In addition, please check the applicable status for each substance.

 
STORED
PROCESSED
UTILIZED
DISPOSED
SECTION D – CERTIFICATION
I certify that, to the best of my knowledge and belief, the information contained in this questionnaire is complete and accurate.
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