Notice of Intent to Discharge Industrial Wastewater

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Please correct the field(s) marked in red below:

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
NAME, TITLE AND TELEPHONE NUMBER OF INDUSTRY REPRESENTATIVE:
 *
NAME, TITLE AND TELEPHONE NUMBER OF INDUSTRY REPRESENTATIVE:
 
 *
 Reason for Filing Notice of Intent:
Reason for Filing Notice of Intent:

Volume Of
 Existing Discharge:  __________________  Proposed Discharge:
Volume Of Existing Discharge: __________________ Proposed Discharge:
 
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.
 
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:

Owner's Signature Required