Step One

2. Mandatory Completion of Survey Form for Sewer Customers

   extended deadline to 10/21/22

   Please read before completing the survey form:

   We are currently engaged in a study to determine the nature of wastewater discharged by businesses. This study is called an "Industrial User Survey." The state periodically collects this information to ensure that non-domestic sources of wastewater are identified. The information is used to ensure that these discharges do not pose a threat to the Clean Water Facility and that proper controls are in place for significant sources of polluted water. 

   In order to allow continued sewage service to our non-residential customers, we must obtain responses to the survey questions below to the best of your ability. 

   Submission Deadline

   The deadline is extended to October 21, 2022.

   The City of Oak Harbor will collect and tabulate this information in compliance with the Washington State Department of Ecology requirements for our Clean Water Facility discharge permit. 

   The thorough and accurate completion of this form is important.

   Failure to complete the form is an offense punishable by enforcement actions which include termination of treatment services, and/or civil and criminal penalties for knowing violations. 

   
   

4. SECTION A - GENERAL INFORMATION (Required for all businesses)
6. Business Name*
7. Phone Number*
9. Full Mailing Address of Business Offices*
11. City*
12. State*
13. Zip Code*
15. Facility Address (If different than Mailing Address)
17. City
18. State
19. Zip Code
21. Environmental Contact

    Fill in the name of the person that handles environmental policies, procedures, and materials. This may be the same person that owns the business or a facilities staffer. 

23. Name of Environmental Contact*

     

24. Phone Number*
26. Email Address*
28. Primary Business Category*

    Provide a narrative description of the types of operations conducted. (Include any activities from which wastewater is produced.)

29. Unified Business Identification Number (UBI#)*

    This number may be your UBI#, Federal Tax Identification Number, or Social Security Number for the business owner. 

31. Standard Industrial Classification (SIC) Code(s)

    Find the SIC codes online. 

    Select the SIC codes that are closest to your type of business. If more than one is selected, enter the SIC codes separated by commas. 

33. Applicable Standard Industrial Classification (SIC) Code(s)*
35. Is any wastewater other than from domestic use of restrooms, showers, kitchens, or laundry rooms (excludes commercial services) discharged to either the sewer, a storm drain, or the ground?
    -- Select One --YesNo

37. READ BEFORE SUBMITTING

    You must sign the statement below. 

    The survey cannot be accepted as complete until you sign and date the form.  

    If you selected YES to the question above, you will be contacted by the City's Storm Drain/Wastewater Collections Compliance Inspector/Educator

    If you responded NO to the question above, you have completed the Washington State Department of Ecology and City of Oak Harbor process. 

39. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that you completed responded to the question, "Is any wastewater other than from domestic use of restrooms, showers, kitchens, or laundry rooms (excludes commercial services) discharged to either the sewer, a storm drain, or the ground?" as No. 

    1. I agree.
41. Electronic Signature*
42. Date Signed*
    Date Signed
44. Job Title*

    Type your job title for reference

46. DISCLOSURE

    Title 40 of the Code of Federal Regulations Part 403 Section 403.14 requires information provided in this questionnaire identifying the nature and frequency of discharge to be available to the public without restriction. Requests for confidential treatment of other information shall be governed by procedures specified in 40 CFR part 2 and applicable State Law. Should a discharge permit be required for your facility, the information in this questionnaire may be used to issue the permit.

Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit | Go Back