This form must be completed by all Users identified in subsec. 26.50.028 of the Anchorage Municipal Code, before commencing discharge into the Municipality of Anchorage sewerage system. Attach additional pages if necessary to provide complete response.

ANCHORAGE WATER AND WASTEWATER UTILITY

3000 Arctic Boulevard

Anchorage, Alaska 99503

SECTION I - TO BE COMPLETED BY USER

 *

SECTION I - TO BE COMPLETED BY USER

Company Name:

Division Name:

Facility Address:

Mailing Address:

Description of Business:

Legal Description:

Private System #:

NAME, TITLE AND TELEPHONE NUMBER OF INDUSTRY REPRESENTATIVE:

 *

NAME, TITLE AND TELEPHONE NUMBER OF INDUSTRY REPRESENTATIVE:

Name

Title

Telephone Numberext.

 

 *

Date Discharge is Expected to Begin:

NAICS (North American Industry Classification System) Code for Facility:

 Reason for Filing Notice of Intent:

Reason for Filing Notice of Intent:

Purchase of an Existing Facility

Construction of a New Facility

Proposing to Discharge from a Facility Where There is Currently No Discharge

Significantly Altering the Volume or Characteristics of an Existing Discharge

---

Volume Of

Existing Discharge:

__________________

Proposed Discharge:

Volume Of Existing Discharge: __________________ Proposed Discharge:

gal/day	process wastewater
gal/day	domestic wastewater
gal/day	cooling water

 

Describe Process that will Result in the Discharge of an Industrial Process Wastewater:

List all Chemicals/Pollutants that might be Present in your Proposed Discharge:

Describe any Wastewater Pretreatment Method and Facilities to be Used:

I am familiar with the Discharge Standards, Monitoring and Reporting Requirements, and Other Provisions of Chapter 26.50 of the Anchorage Municipal Code.  The information contained in this notice is familiar to me and to the best of my knowledge and believe such information is true, complete, and accurate.

Signature

 

Date

Title

Telephone Numberext.

SECTION II - TO BE COMPLETED BY AWWU  APPROVAL TO COMMENCE PROPOSED DISCHARGE IS SUBJECT TO:

SECTION II - TO BE COMPLETED BY AWWU  APPROVAL TO COMMENCE PROPOSED DISCHARGE IS SUBJECT TO:

Control Manhole Required

Control Manhole Waived

Attached Special Conditions

Owner's Signature Required

Signature

 

Date

Title

Telephone Numberext.

Page 1 / 1