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Industrial Waste Survey
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Industrial Waste Survey
Step
1
of
4
25%
Please complete all questions of the survey. Contact Reese Berry with questions on completing the survey at (630) 969-0664.
Business Name:
(Required)
Address:
(Required)
Street Address
City
ZIP Code
Site Representative:
(Required)
Phone number:
(Required)
SIC/NAICS Code(s):
(Required)
Ex: 3471, 3541, etc.
What services are performed or products produced at this site?
(Required)
What raw materials are use on this site?
(Required)
Number of units in building occupied by this company:
(Required)
Stand-alone building
Multiple units
Number of units:
(Required)
Number of Employees:
1st Shift
2nd Shift
3rd Shift
Operating Days:
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Operating Hours per day:
Mon-Fri
(Required)
Sat-Sun
(Required)
Date that service/production began at this site:
(Required)
MM slash DD slash YYYY
Does your business do manufacturing at this facility?
(Required)
Yes
No
If yes, is water used in your manufacturing process?
(Required)
Yes
No
Does your business do assembly or fabrication at this facility?
(Required)
Yes
No
Does your business have an office at this facility?
(Required)
Yes
No
Does your business have a warehouse at this facility?
(Required)
Yes
No
Does your business have a cafeteria that prepares meals at this facility?
(Required)
Yes
No
Do you discharge process wastewater (non-domestic) to the sewer?
(Required)
Yes
No
Description of process waste discharged:
(Required)
Does your business have any process wastewater hauled offsite?
(Required)
Yes
No
Description of process waste hauled:
(Required)
Do you treat your wastewater discharge at any point within your process?
(Required)
Yes
No
Does your business store liquid in drums (typically 55 gal.)?
(Required)
Yes
No
If yes, how many drums?
(Required)
Less than 5
5 or more
Drum general substance:
(Required)
Does your facility store liquids in totes or bulk tanks?
(Required)
Yes
No
If yes, how many totes:
(Required)
How many bulk tanks:
(Required)
Tote or bulk tank general substance and number of gallons:
(Required)
Are any inks or dyes used?
(Required)
Yes
No
If yes, are any inks or dyes washed down the drain?
(Required)
Yes
No
Does your facility precondition your water?
(Required)
Yes
No
If yes, check how:
(Required)
Water softener
Reverse osmosis
Ion exchange
Distilled
Does your facility use any materials which include, but are not limited to, cleaning products, raw materials or chemicals in a process which contain PHOSPHORUS in the ingredients?
(Required)
Yes
No
Has your facility been issued any Federal, State or local environmental permits?
(Required)
Yes
No
Have you sampled your wastewater discharge for per- and polyfluoroalkyl substances (PFAS)?
(Required)
Yes
No
Does your facility use chemicals containing PFAS in your processes or operations?
(Required)
Yes
No
In the past
Does your business perform electroplating, metal finishing or circuit board manufacturing?
(Required)
Yes
No
In the past
If yes, do you use demisters/defoamers/surfactants for any plating or etch tanks?
(Required)
Yes
No
In the past
Do you treat paper or packaging with coatings or treatments for oil and moisture repellency?
(Required)
Yes
No
In the past
Do you treat leather, textile, fabric or carpet for stain, oil or water repellency?
(Required)
Yes
No
In the past
Does your business manufacture parts with polytetrafluoroethylene (PFTE) coatings?
(Required)
Yes
No
In the past
Do you coat parts with non-stick coatings similar to PFTE?
(Required)
Yes
No
In the past
Does your business have a site with soil or groundwater contamination from industrial wastes?
(Required)
Yes
No
If yes, do you have an ongoing groundwater cleanup or investigation?
(Required)
Yes
No
Does your business utilize AFFF (Class B) foam for fire suppression or firefighter training?
(Required)
Yes
No
In the past
Does your business clean transportation tanks or other containers that hauled waste or materials?
(Required)
Yes
No
Does your business have an industrial or commercial laundry facility?
(Required)
Yes
No
In the past
Upload SDS sheets
Drop files here or
Select files
Max. file size: 64 MB.
Please provide SDS sheets for all chemicals used in your business operations and processes. If not currently feasible, we will follow up via email to retrieve them.
Additional information
Please use this space if necessary to answer/explain your responses.
Complete the following Certification Statement
I certify that I am authorized to act on behalf of the business identified in this document on these matters. 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 on my inquiry of the person or persons who manage the system or those persons directly responsible for gathering the information, the information 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 imprisonment for knowing violations.
Signature
(Required)
By printing your name here, you acknowledge that all the above information is correct.
Title
Email address
(Required)
A copy of the completed survey will be emailed to you.
03/14/2026
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