Class I Industrial User Survey

Class I Industrial User Survey

All industrial dischargers of nondomestic wastewater are required to complete the Industrial User Survey under Section 13.08.150 of the Sewer Use Ordinance.

Completion of the permit application and survey will assist the Environmental Compliance Program in determining if a permit is required for your type of business.

New or proposed point of dischargeExisting, but unpermitted point of dischargeNew OwnershipRenewal

CorporationPartnershipLLCSole Proprietor*

First NameLast NameTitle

Street Address

Street Address Line 2

CityState

Zip Code

First NameLast NameTitle

Street Address

Street Address Line 2

CityState

Zip Code

Facility AddressMailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Facility AddressMailing AddressBilling Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

:HourMinutesAM/PM Option

Until

until :HourMinutesAM/PM Option

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City of San Luis ObispoWellPrivate Water System

Unsure? Use this website to help: https://siccode.com/sic-code-lookup-directory

Yes (Please enclose a copy below)NoNot applicable. There are no floor drains and/or the facility only discharges domestic wastes.

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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 qualified personnel properly gather and evaluate the information submitted. Based upon 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/or imprisonment for knowing violations.

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