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Murfreesboro Water and Sewer Department (City of Murfreesboro)

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Murfreesboro Water and Sewer Department
300 NW Broad Street, P.O. Box 1477 • Murfreesboro, Tennessee 37133-1477
phone: 615-890-0862 • fax: 615-896-4259
Rev. 01/20/06 Page 1 of 5
Application For Sewer Charge Reduction
Metered Water Not Discharged To Sewer
SECTION A - GENERAL INFORMATION
A-1. Business Name:
Provide the official or legal name of the business.
A-2. Facility Address
Provide the physical location of the facility.
Street:
City:
State:
Zip:
A-3. Business Mailing Address
Provide the address where any correspondence is to be sent.
Street:
City:
State:
Zip:
A-4. Designated Contact
Person authorized to represent this business in official matters.
Name: Phone:
Title:
A-5. Alternate Contact
Additional contact if primary contact is not available.
Name: Phone:
Title:
A-6. Type of Business:
Identify the type of business and provide a brief description of the production or services performed.
Print Form
Murfreesboro Water and Sewer Department Application for Sewer Charge Reduction
Rev. 01/20/06 Page 2 of 5
SECTION B – OPERATIONAL CHARACTERISTICS
B-1. Annual Operation
Indicate type of annual operation. If seasonal or intermittent, describe times of operation below
Business Activity:
Continuous, throughout the year Seasonal or intermittent
Waste Discharge:
Continuous, throughout the year Seasonal or intermittent
B-2. Periodic Shutdown
Does operation cease during periods of maintenance, vacation, etc.?
YES NO
If YES, describe reasons and periods of shutdown below.
B-3. Shift Information
Day of Shifts Per
Employees Per Shift Shift Begin & End Times
Week Day
1
ST
2
ND
3
RD
1
ST
2
ND
3
RD
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
SECTION C – WATER USE INFORMATION
C-1. Water Usage
Provide average usage per
day. Indicate whether the volume is measured [M] or estimated [E].
Type of Use Volume Used Units (gals, cu.ft.) M/E
a.
Domestic (restrooms, etc.)
b.
Contact cooling
c.
Non-contact cooling
d.
Boiler/tower feed
e.
Process
f.
Air pollution control
g.
Contained in product
h.
Washdown
i.
Irrigation
j.
Storm water runoff to sewer
k.
Other:
l.
Other:
Murfreesboro Water and Sewer Department Application for Sewer Charge Reduction
Rev. 01/20/06 Page 3 of 5
C-2. Water Sources (Indicate all that apply)
Private well
Surface water
Murfreesboro Water Department
Storage tank (volume & type)
Other source (explain)
C-3. Service Account Numbers(s):
SECTION D - WASTEWATER INFORMATION
D-1. Sewer Connections
List size, location, & average flow in gallons per day of each connection.
Size (in.) Flow (GPD) Location
#1
#2
#3
D-2. Wastewater Flow
Indicate the hours, times and volumes that non-domestic wastes are discharged.
Day of Duration of
Discharge Flow Rates
Hours of
Week Discharge
Peak Hourly Maximum Daily
Daily Average
Discharge
Mon. to
Tues. to
Wed. to
Thurs. to
Fri. to
Sat. to
Sun. to
D-3. Wastewater Reclamation
Indicate if any reclamation process is utilized. If YES, describe below.
YES NO
Murfreesboro Water and Sewer Department Application for Sewer Charge Reduction
Rev. 01/20/06 Page 4 of 5
D-4. Sewered Wastes
Provide the average volume in gallons per day of wastes that are
discharged into the sewer system.
Include domestic, process, wells, or other.
Description of Waste
Volume
Generated
Percent
of Total
M/E
Totals:
Describe the method(s) used to determine the volumes indicated above:
D-5. Non-Sewered Wastes
Provide the average volume of wastes generated that are not
discharged into the sewer system.
Include storm sewer, surface water, ground water, injection, evaporation, hauled, or other.
Type of Waste
Volume
Generated
Units
(gal, lb, etc.)
Frequency
(per week, yr, etc.)
Disposal
Method
M/E
Describe the method(s) used to determine the volumes indicated above. :
Murfreesboro Water and Sewer Department Application for Sewer Charge Reduction
Rev. 01/20/06 Page 5 of 5
SECTION E - AUTHORIZED SIGNATURES
E-1. Authorized Representative Statement
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 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.
Name Date
Title Phone
Signature
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Completed 14 July 2020

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