Industrial Waste Survey

This form is for your business to determine types and sources of wastewater that are discharged to the Fox River Water Reclamation District. This form must be completed in accordance with the District's Sewer Use Ordinance and USEPA requirements. If you have any questions or concerns while completing the form, please contact the District's Industrial Pretreatment Coordinator.

The Fox River Water Reclamation District's Sewer Use Ordinance requires that an Authorized Representative of the User sign all reports to the District. Authorized Representative is defined as a Person responsible for Principle Business decisions or other policy decisions for the facility.

To my best of my Knowledge the information on this form is true and accurate (Please type your name as an indication of your signature)