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Pretreatment Survey Form

  1. Does your business do or have any of the following:

  2. Laundry facilities or service?*

  3. Is phosphorus detergent used?*

  4. Develop photographic materials?*

  5. Serve or prepare food?*

  6. Handle hazardous waste?*

  7. Deep fry food?*

  8. Clean oily/greasy parts?*

  9. Process/manufacture dairy foods?*

  10. Vehicle wash bays?*

  11. Grease/oil waste?*

  12. Grease trap?*

  13. Industrial spray painting?*

  14. Oil water separators?*

  15. Phosphate rinse system?*

  16. Change vehicle fluids?*

  17. Electroplate metals/parts/circuitboards?*

  18. Basement sump pump?*

  19. 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.

  20. Leave This Blank:

  21. This field is not part of the form submission.