BUSINESS WASTE SURVEY

Initial Information

Business Name*

SIC # (if applicable)

Business Address*

Apt/Unit

City*

State

Zip Code*

Owner Last Name*

Owner First Name*

Owner Middle Name

Owner Address*

Apt/Unit

City*

State*

Zip Code*

Owner Phone*

Business Operations

Which days of the week is the business in open? (Check all the apply)* Mon Tues Wed Thur Fri Sat Sun

Hours of Operations From*

Hours of Operations To*

Number of Employees*

Type of Commercial activities (Check all that apply)*

Provide a brief description of the process or business function that involves water use:*

Check off any item used on a daily or regular basis:*

For any of the item(s) used on a daily or regualr basis: Will you discharge wastewater into the sanitary sewer that may contain any quantity of one of the items or other products as a result of the business or cleaning actitivies? *

Yes

No

Will you use any device to pretreat the wastewater prior to discharge into the sanitary sewer? *

Yes

No

Do you employ/hire a Waste Disposal Service other than county wastes services? *

Yes

No

Water Source

Please check a water source: *
Lee County Water Ground Water Well Surface Water (Pond, Lake, etc)

Estimated Use in Gallons/Day*

Metered? *

Yes

No

Grease Traps (Applies to Food Preperation Activities or Mechanical Shops)

Are grease traps/oil separators in service? *

Yes

No

Do you employ/hire a Waste Hauler other than county wastes services? *

Yes

No

Person completing this form

Last Name*

First Name*

Middle Name

Title*

Email*

Initial Information

Business Operations

Water Source

Grease Traps (Applies to Food Preperation Activities or Mechanical Shops)

Person completing this form

Signature*