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<br />WASTEWATER SURVEY FOR NONRESIDENTIAL ESTABLISHMENTS~ <br />APPLICATION FOR WASTEWATER DISCHARGE PERMIT <br /> <br />SECTION A - GENERAL INFORMATION <br /> <br />A.1. Company name, mailing address, and telephone number: <br /> <br />Zip Code <br /> <br />Telephone No. <br /> <br />A.2. Address of production or manufacturing facility. <br />above, check [].) <br /> <br />(If <br /> <br />s~e <br /> <br />as <br /> <br />Zip Code <br /> <br />Telephone No. <br /> <br />A.3. Name, title, and telephone number of person authorized <br />represent this firm in official dealings with the City~ <br /> <br />to <br /> <br />A.4. Alternate <br />herein <br />N~e <br /> <br />person <br /> <br />to <br /> <br />contact <br /> <br />concerning <br /> <br />information <br /> <br />provided <br /> <br />Title <br /> <br />Tel.No. <br /> <br />A.5. Identify the type of business conducted (auto repair, machine <br />shop, electroplating, warehousing, painting, printing, meat <br />packing, food processing, etc.). <br /> <br />Note to Signing Official: In accordance with Title 40 of the <br />Code of Federal Regulations Part 403 Section 403.14, information <br />and data provided in this questionnaire which identifies the <br />nature and frequency of discharge shall be available to the <br />public without restriction. Requests for confidential treatment <br />of other information shall be governed by procedures specified in <br />40 CFR Part 2. <br /> <br />This is to be signed by an authorized official of your firm <br />after adequate completion of this form and review of the <br />information by the signing official. <br /> <br />I have personally ex~ined and ~ familiar with the <br />information submitted in this document and attachments. <br />Based upon my inquiry of those individuals immediately <br />responsible for obtaining the information reported <br />here, I swear that the submitted information is true, <br />accurate and complete. I am aware that there are <br />significant penalties for submitting false information, <br />including the possibility of fine and/or imprisonment. <br /> <br />Date <br /> <br />Signature of Official <br />(Seal if applicable) <br /> <br />-7- <br />