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2. Company Name*
4. Business Address*
6. City*
7. State*
8. Zip*
10. Business Phone Number*
11. Email Address*
13. First Name of Person Completing this Survey*
14. Last Name*
16. Please describe the manufacturing or service activity at this facility*
18. List products produced
20. List raw materials used
21. List catalysts/intermediates
23. List by-products
25. Is this facility connected to the sanitary sewer system?*

    1. Yes
    2. No
27. If Yes, what is the flow to the sanitary sewer?(gal/day)
29. Are all waste waters discharged to the sanitary sewer?*

    1. Yes
    2. No
31. Is an analysis of the wastewater available?*

    1. Yes
    2. No
33. Is hazardous waste created at this facility?*

    1. Yes
    2. No
35. For questions or assistance contact the Pretreatment Coordinator at 937-339-1410
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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field