Commercial Wastewater Discharge Application

2176 W. Treatment Plant Rd., St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Commercial Wastewater Discharge Application

*NO process water shall be discharged into the sanitary sewer OR storm drain for any mobile business.
Application Date*

MonthDayYear
Date
Applicant*

NewExisting
Name of Business*
Name of Owner / Contact*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Contact Email Address*
example@example.com
Form Completed By:*

First NameLast Name
Title*
A. General Information

Answer ALL questions as completely as possible.
Type of Business (Check all that are applicable)*

Car Wash (Self Serve)Car Wash (Full Service)Mobile Car Wash/Detail ServicesDiesel / Truck ServiceAuto RepairPressure WashingTrash Can CleaningDumpster CleaningOther
Days of Week of Operations*

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Hours of Operation*
B. Business Overview
Briefly describe services rendered*
Number of Service Bays*
Number of Floor Drains*
Are there mud boxes in the service bays?*

YesNoN/A
If yes, how many?
Is a sand/oil interceptor installed and utilized?*

YesNo
If a pretreatment device is used other than a sand/oil interceptor, please describe here.*
Are solids and oils regularly removed from the interceptor or other pretreatment device?*

YesNoN/A
If yes, how often?
Name of the wastehauler that services the interceptor
Final disposal destination for the contents in the interceptor*
Do you clean commercial trucks?*

YesNo
Do you clean chemical tankers?*

YesNo
Describe and note quantities of chemicals used or stored on site. (Attach documents if necessary)*
Attachments

Browse Files

Cancelof
Describe secondary containment you will provide to prevent chemical spills or leaks from entering the sewer*
Amount in gallons per day of process wastewater discharged to the sewer (not referring to restroom wastewater)*
C. Signatory Requirement
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate information submitted. Based on my inquiry of the person or people who manage the system, or those people directly responsible for gathering the information, the information submitted is to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Name*

First NameLast Name
Title*
Date*

MonthDayYear
Date
Signature of authorized representative*

Clear
*Please allow up to 48-hours for review during regular business days, and up to 72-hours if submitting during weekends or holidays.
SGRWRF Pretreatment Department Use Only
Is the facility in compliance with the source control program:

YesNo
Follow-Up action required:

YesNo
If follow-up required, explain:
Inspector:
Date

MonthDayYear
Date
Should be Empty:

Commercial Wastewater Discharge Application

A. General Information

B. Business Overview

C. Signatory Requirement