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City of Everett Public Works <br />For COE-PW Use Only <br />4--7r PURL/C WORKS <br />Discharge <br />Discharge Authorization Requests <br />Received: <br />c/o Operations Superintendent <br />Staff: <br />3200 Cedar Street <br />Approval No <br />Everett, WA 98201 <br />INDUSTRIAL DISCHARGE APPROVAL REQUEST FORM <br />A. General Information: <br />1. Company Name: <br />Contact Person: <br />24 hour Contact Phone: <br />Email Address: <br />Mailing Address: <br />2. Site Name: <br />Site Address: <br />3. Requester Name/ Company: <br />Requester Address: <br />Email Address: <br />4. Billing Contact Name: <br />B. Waste Characteristics/Site Information: <br />1. Describe discharge: <br />2. Describe your project and why discharge authorization is required: <br />Title: <br />(30 minute response required) <br />Phone: <br />Phone: <br />3. Are there any MSDS sheets applicable to the waste? _ Yes _ No <br />(Attach relevant MSDS sheets.) <br />4. Source of waste (groundwater, construction dewatering, etc.): <br />5. Volume of waste: (gallons) Rate of discharge (max gpm): <br />6. Frequency of discharge: __ One-time _ On -going Continuous flow? Yes —No <br />If on -going, please note the number or frequency/requested duration of discharge events per year: <br />7. Requested start date: <br />8. Identify proposed point of discharge: <br />Page 1 of 2 <br />