Commercial/Industrial - Pretreatment Survey
Business Name:
Facility Address:
Street City State Zip
Mailing Address:
(if different from facility) Street City State Zip
Contact Person:
(Name of person City of Sumner can contact for site visit) Phone
E-Mail: Title:
Nature of business:
Number of employees: Normal operation hours:
Full-time Part-time
NATURE OF DISCHARGE (Check the box that applies)
This business or facility will only discharge domestic or sanitary wastewater into sewer. (i.e. there
are no washdown, batch or process drains, grease trap or amalgam separator.)
If you check this box you may skip to the Certification Statement.
Facility creates a process waste but the process waste will not discharge to City of Sumner sewer
system.
Check this box if there will be discharges other than domestic or if you have floor or process
drains.
WASTEWATER PRETREATMENT
Indicate type(s) of treatment given:
None Biological Treatment
Grease Interceptor Chlorination
Grinding Holding tank
Oil & water separator pH adjustment
Screening Sedimentation
Amalgam Separator Other
WATER BALANCE
WATER RECEIVED FROM
Choose one:
WASTEWATER
DISCHARGED TO
Choose one:
Water Used for:
City of Sumner
Water System
Other
(indicate)
City of Sumner
Sewer System
Other
(indicate)
Sanitary
Processes
Other
TOTAL
GPD Gallons per Day / CFD Cubic Feet per Day
CFD
CFD
Andria Swann, Pretreatment Coordinator
8979
RAW MATERIALS AND CHEMICALS USED IN PROCESS
Brand Name
Purpose
Daily Amounts
Avg. Max
.
COMMON PRIORITY POLLUTANTS IN DISCHARGE
Check box if present in wastewater:
None
Aluminum Antimony Arsenic
Barium Benzene Beryllium
Boron Bromide Cadmium
Chromium Cobalt Copper
Cyanide Fluoride Formaldehyde
Lead Mercury Molybdenum
Nickel Phenols Radioactivity
Selenium Silver Solvents
Sulfate Sulfide Sulfite
Titanium Tin Total Petroleum Hydrocarbons
Vanadium Zinc Toxic Organics (please specify)
Comments:
If you have questions on completing this pre-application form, please contact the City
of Sumner Pretreatment Coordinator at (253) 299-5713.
Sign the certification below and mail to the return address listed.
CERTIFICATION STATEMENT:
I certify under penalty of law that 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.
Signature Date
Printed Name Title
City of Sumner Public Works
Attn: Pretreatment Coordinator
1104 Maple Street
Sumner, WA 98390
Note: Yearly updates may be requested (no fee required) based on any changes, which may occur in your business.
Page 2
RETURN COMPLETED FORM:
PRINT & MAIL TO
EMAIL TO
andrias@sumnerwa.gov
Directions for Completing Commercial/Industrial - Pretreatment Survey
1. Business Name: This is the name of business.
2. Facility Address: The physical address of the facility.
3. Mailing/Billing Address: Mailing address of the facility.
4.
Contact Person and Telephone Number: The facility contact and telephone number.
5. Facility Telephone Number: The telephone number of the facility.
6. Email Address: The email address of the contact person.
7. Title: Title of contact person.
8. Nature of business: Short detail of type of business.
9. Number of Employees: List number of Full-time and Part-time employees.
10. Normal Operation Hours: The hours the facility is open.
11. Nature of Discharge: Check the appropriate box that best describes the type of wastewater
that the facility will discharge into the City of Sumner sewer system.
12.
Wastewater Pretreatment: Indicate the type of treatment for process waste generated at
facility.
13.
Water Balance: Please provide approximation of total water used for sanitary and production
needs.
14. Raw Materials and Chemicals used in process: list all chemicals used in production process.
15. Common priority pollutants in discharge: If know, indicate which priority pollutants may be present
in process wastewater discharge. Include analysis report if available.
16. Certification Statement: Sign the certification statement.
If you have questions or need assistance, please contact Andria Swann,
City of Sumner Pretreatment Coordinator, at 253-299-5713, or at andrias@sumnerwa.gov.