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Industrial Waste Questionnaire
IWQ Document Required to Meet EPA Regulations Revised 2/2017
4. Is your business a Food Service Establishment (FSE)*?
* “Food Service Establishment,” (FSE) is any facility engaging in preparing food for consumption by the public such as, but not limited to, restaurants,
commercial kitchens, caterers, hotels, bakeries, public and private schools, hospitals, or care institutions.
If yes, please fill out the Grease Interceptor Sizing Form
(attached)
and attach a kitchen design plan*.
* The kitchen design plan should include drawings displaying the location of all kitchen equipment, floor sinks, and floor drains. Hand drawings or copies
of plumbing/equipment plans are acceptable.
5. Indicate the type and amount of solutions or materials used in manufacturing, cleaning, or other
operations whose containers exhibit hazard warning labels.
(Attach additional sheets as needed or MSDS documents.
Amounts used should be listed in gallons/per day).
_______________________________________________________________________________________
_______________________________________________________________________________________
6. Description of facilities
(Kitchen, number of restrooms, laundry facilities, chemical storage, etc.)
:
_______________________________________________________________________________________
_______________________________________________________________________________________
7. Are there any floor drains in the work storage areas at your facility?
If yes, please list location(s): ____________________________
8. Water use
(What it is used for and the approximate quantities in gallon/per day?)
:
_______________________________________________________________________________________
“Domestic” (sanitary) wastewater is liquid wastes: (a) from the non-commercial preparation, cooking, and handling of food, (b) containing only human
excrement and similar matter from the sanitary conveniences of dwellings, commercial buildings, industrial facilities, and institutions. All other
wastewater should be considered “Industrial.”
Describe any pretreatment devices or processes used for treating wastewater or sludge.
(Grease interceptor,
DAF, filtration, pH adjustments, etc.)
: _______________________________________________________________
I certify under penalty of law that I have personally examined and am familiar with the information submitted in
this document and attachments. Based upon my inquiry of those individuals immediately responsible for
obtaining this information reported herein, I believe that the submitted information is true, accurate, and
complete. I am aware that there are significant penalties for submitting false information.
Name: ____________________________________ Title: _____________________________
(Please Print)
Signature: _________________________________ Date: _____________________________
Yes No
Domestic Industrial
. Certificate of Information
III. Type of Wastewater Discharged into Municipal Sewer
