Wastewater Discharge Questionnaire & Permit Application

Business Information

Mailing Address
Facility Address

An Authorized Representative is the principal executive officer of at least the level of Vice President of a corporation; a general partner or proprietor of a partnership or proprietorship, or a duly authorized representative of the individuals designated above.

Note to Signing Authorized Representative
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 the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons 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.

Use your mouse (desktops and laptops) or finger (mobile devices) to draw your signature above.