Name of Facility:
Date: Map/Lot Number:
6/17/15 - 2 - Sewer Application Screening Questionnaire
Is any water used within the space to be permitted? (Answer yes or no for each line)
Bathrooms ☐Yes ☐No*
Lunchroom ☐Yes ☐No*
Food Preparation ☐Yes ☐No*
(Other than microwave or vending)
Showers ☐Yes ☐No*
Compressor ☐Yes ☐No*
Boiler ☐Yes ☐No*
Cooling Tower ☐Yes ☐No*
(For facility climate control)
Cooling Tower ☐Yes ☐No
(Used for production)
Manufacturing ☐Yes ☐No
Assembly ☐Yes ☐No
Production ☐Yes ☐No
Processing ☐Yes ☐No
Research & Development ☐Yes ☐No
Janitorial ☐Yes ☐No*
Emergency Shower ☐Yes ☐No*
Photo Processing ☐Yes ☐No
Laboratory ☐Yes ☐No
(Including educational)
Medical or Dental Laboratory or Service ☐Yes ☐No
Washing of Anything Other Than Hands ☐Yes ☐No
Swimming Pool or Spa ☐Yes ☐No
*If associated with * from above, IPP Application may not be required.
Note:
Vehicle Service could include:
Fuel Station
Painting
Auto Body Rework/Repair
Oil Changes
Radiator Work
Engine Repair
Washing
Detailing
Battery
Institutional could include:
Educational
Medical
Personal Service Establishment could include:
Hair Salon
Barber Shop
Manicure/Pedicure (Nail Salon)
Health Spa
Dry Cleaner
Massage Therapy
Cobbler
Tattoo Parlor
Body Art/Piercing
