Industrial Waste Survey Short Form
This form has been sent to your business to determine types and sources of wastewater that
are entering the CITY OF HENDERSONVILLE WWTP. This form must be completed
(POTW Name)
in accordance with section 52-280 of our Sewer Use Ordinance. The Sewer Use Ordinance
can be examined during normal business hours at the address listed below. If you have any
question or concerns while completing the form please contact,
Ms. Gracie Erwin at (828) 697-3057
(Environmental Compliance Coordinator Contact and Phone Number)
Name of Business
Address
City/State/Zip Code
Telephone Email:
Number of Employees
What Standard Industrial Classification (SIC) Code(s) do you report under:
, , , .
Briefly describe your business. Include products manufactured or services performed.
_________________________________________________________________________
_________________________________________________________________________
Please list all water uses and approximate volume used in gallons per day for each use,
including facility washdown water.
Water Use Volume Use
,
p
Process:
Facilit
Washdown
Domestic (bathrooms, cafeteria)
Total:
Our Sewer Use Ordinance requires that an Authorized Representative of the User sign all
reports to Hendersonville Water and Sewer. Authorized Representative is defined as a Person
responsible for Principal Business decisions or other policy decisions for the facility.
To the Best of my knowledge the information on this form is true and accurate.
Signature ___________________________________ Date ___________________
Print _______________________________________ Title ______________________
Return this form within 30 days to: Mail to: Hendersonville Water and Sewer
305 Williams Street
Email to: eerwin@hvlnc.gov Hendersonville, NC 28792
Environmental Compliance Coordinator
Failure to return this form is enforceable in accordance with the Sewer Use Ordinance.
IWS Short Form
Filename: My Documents\IWS\forms\IWS Short Form2006.doc
Revision Date: March 17, 2006
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signature
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