Wastewater Discharge Survey Page 1
Project Name: __________________________________________________________________
Project Location: _______________________________________________________________
Type of business (check all that apply) that will be conducted at the facility discharging into
the Fulton County wastewater collection system:
□ General Office/Retail
□ Medical Office
□ Hospital
□ Biogenetic Laboratory
□ Car Wash
□ Chemical Storage & Sale
□ Laundromat /
Drycleaner
□ CLF (Congregate Living Facility
□ Food Preparation and Processing:
□ Funeral Home
□ Medical Waste Storage & Processing
□ Automotive Repair Shop
□ Fuel Storage
□ Photo Development
□ Dental Office
□ Others (Specify) ________________________________________________
Name of Property Owner/Developer/Authorized Agent:________________________________
Address: _____________________________________________________________________
Telephone Number: ____________________________________________________________
Projected Connection Date: ______________________________________________________
List all chemicals/pollutants other than Domestic Waste that might be present in your
proposed discharge:
_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
WASTEWATER DISCHARGE SURVEY
Dept. of Industrial Monitoring
7472 Cochran Road, College Park, GA 30349
404-612-0212-office
404-612-2931-fax
ngozi.daramola@fultoncountyga.gov
