Request for New Service Turn-On Commercial

Transcription

1 Request fr New Service Turn-On Cmmercial Please cmplete the frm belw t have yur cmmercial service turned n at an established cmmercial lcatin that already has a water meter. This frm must be submitted at least 24 hurs prir t when yu wuld like service cnnected t yur cmmercial accunt. New services are turned n Mnday thru Friday. Accunt Name: Name f Business (MUST match EIN/Federal ID number) d/b/a, if applicable Cntact Infrmatin: Last First Middle Initial Mailing address Unit # (if applicable) City Zip Address Phne numbers Fax Number * EIN/Federal ID Number Identificatin: Last 4 digits f Scial Security Number (ptinal) Date f Birth (ptinal) * New Service Address t Cnnect: Street Address Unit # (if applicable) City Zip Preferred Cnnectin Date:

2 D yu currently have service with the Authrity? YES NO D yu need t discnnect that service? YES NO If yes, please specify the preferred discnnect date and prvide yur custmer infrmatin. * Street Address Unit # (if applicable) City Zip Preferred Discnnectin Date: Cmments: Please verify that yu have entered yur infrmatin crrectly befre submitting this frm. When submitting this request fr new service yu are acknwledging that it is yur respnsibility t be certain that the internal plumbing has been secured and all faucets are in the OFF psitin prir t yur initiatin f service.

3 Clay Cunty Utility Authrity 3176 Old Jennings Rad Middleburg, Flrida Telephne (904) Fax (904) Wrking tgether t prtect public health, cnserve ur natural resurce, and create lng-term value fr ur ratepayers. Cmmercial Custmer Survey Business Name: Service Address: Type f Business: CCUA Rute #: Cntact Persn: Phne #: Fax #: Primary Business: CHECK ALL THAT APPLY Health Care Prvider Hspital, Clinic, Labratry Veterinary Medicine Pht Finishing Plating Pesticides/Fertilizers Nail Saln Assisted Living/Nursing Hme Laundry Restaurant Hair Saln/Barber Shp Car Dealership/Service Department Car Wash Dcks/ Dckside Facilities Day Care Other: NAICS Cde: ANSWER YES OR NO TO THE FOLLOWING Is there a private well n the prperty? Are txic chemicals used in the prductin f yur gds/ the service yu prvide? Is there a sprinkler system with chemical injectrs? IF ONE OR MORE OF THE ABOVE APPLY, YOU MUST SCHEDULE AN INSPECTION BEFORE SERVICE IS AVAILABLE. I understand that the CCUA crss-cnnectin cntrl plicy requires the ptable water service at all cmmercial accunts be equipped with a reduced pressure backflw assembly. Furthermre, I agree t install and certify a RP immediately dwnstream f the water meter serving the abve lcatin within 30 days, if ne is nt already installed and certified. I als understand that if a RP is nt installed and perating prperly, ptable water service at this address is subject t terminatin withut any further ntificatin after the 30 days. Cnditins & Cmments: Signature Date

4 Clay Cunty Utility Authrity 3176 Old Jennings Rad Middleburg, Flrida Telephne (904) Fax (904) Wrking tgether t prtect public health, cnserve ur natural resurce, and create lng-term value fr ur ratepayers. NE NEW USER SURVEY (Nn-Residential) General Infrmatin: Cmpany Name: Facility Address: Phne #: Mailing Address: On-site persn authrized t represent business: (name & title) Prperty/Facility Owned r Leased If Leased: Owner s Name: _ Address: Phne #: Year Established at this lcatin & brief descriptin f activities cnducted: Water Usage & Wastewater Descriptin Will this business discharge any wastewater ther than frm restrms t CCUA? If yes, please indicate the surce f the wastewater: Please indicate all chemicals and prducts which may be dispsed f in the sewage system (attach additinal sheets if needed & MSDS sheets if applicable) Chemical/ Prduct Average Quantity (gal/m) Hw much water d yu expect t use? (gal/day) Has this facility s wastewater ever been analyzed? If yes, please attach a cpy. Certificatin: I hereby state that the infrmatin cntained in this survey is familiar t me, and t the best f my knwledge and belief, such infrmatin is true, cmplete, and accurate. Signature Printed Name, Title & Date

5 Clay Cunty Utility Authrity 3176 Old Jennings Rad Middleburg, Flrida Telephne (904) Fax (904) Wrking tgether t prtect public health, cnserve ur natural resurce, and create lng-term value fr ur ratepayers. NE Flr Wax Stripper Questinnaire Cmpany Name: Service Address: Cntact Name: Phne Number: Janitrial Service Name: Cntact Name: Cmpany Address: Phne Number: 1. Des yur cmpany r yur janitrial service cmpany use flr finish r finish stripper prducts that cntain any f the fllwing chemicals? 1. Mnethanlamine 2. Sdium Metasilicate Y/N: Y/N: 2. If yu answered Yes t any f the items under 1 abve, please indicate hw yu plan t eliminate yur discharge f flr finish stripper waste frm the sanitary sewer: 1. Find alternative prducts (bth flr wax & stripper) that d nt cntain the abve listed chemicals. Y/N If yes, please prvide CCUA with a material Safety Data Sheet (MSDS) fr the prpsed chemical. 2. Capture and cntain all flr stripper wastewater prir t discharge t the sanitary sewer and transprt t an industrial wastewater pretreatment cmpany r anther nn-ccua treatment facility fr dispsal. Y/N If yes, please indicate what cmpany yu plan t use. Yu will be required t btain a pretreatment permit frm CCUA and t submit cpied f hauling recrds t CCUA fr review. Cmpany r Facility Name: Cmpany Cntact: 3. Install and maintain n-site facilities t pre-treat the wastewater prir t discharge t the sanitary sewer. Y/N: This ptin will require yur cmpany t btain a permit frm the CCUA fr the facility t perfrm mnitring f the industrial wastewater.

6 Custmer Name : Business Name (DBA) : Occupying Suite N. : Service Address : Bathrm Fixtures Lavatry Cmmde - Tank Cmmde - Valve Urinal Shwer Flr Drain Other Fixtures Utility Sink Mp Sink Wash Sink Bar Sink Hand Sink Kitchen Sink 3 Cmpartment Sink 2 Cmpartment Sink Interir Hse Bib - Wash Dwn Drinking Funtain Flr Drain Hub Drain at Grade Trench Drain Pet Grming Wash Tub Hair Trap Washing Machine Y/N Restaurants N. f Seats Grease Trap Y/N Dishwasher Y/N Cleaners/ Laundry Tp Lad Cmmercial Washer Frnt Lad Cmmercial Washer Lint Trap Y/N Autmtive Repair & Maintenance N. f Bays Interir Hse Bib - Wash Dwn Sand Trap Oil Trap Barber/ Beauty Saln & Spa N. f Styling/Barber Chairs N. f Shamp Bwls N. f Pedicure Statins Washing Machine Y/N Dctr/ Dentist Office N. f Dctrs N. f Dentist N. f Exam Chairs Day Care, Schl/ Church N. f Students N. f Sanctuary Seats Grease Trap Y/N Cmments: Quantity Quantity Quantity Attached Cmmercial Accunts - Fixture Unit Cunt Date : Type f Business : Square Ftage : Drain Size N. f SSB N. f Faucets N. f Faucets N. f Faucets Drain Size N. f SSB Drain Size N. f SSB Drain Size N. f SSB In Drain In Flr Mdel N. Size (Gallns r lbs) Trap Size Size (Gallns r lbs) Size (Gallns r lbs) N. f Hair Traps Dctr Name(s) Dentist Name(s) Size (Gallns r lbs) Mdel N. Mdel N. Mdel N. Mdel N. Attach Flr Plan if Available Cntact Persn : Inspectr : Phne N : Fax Rute N. : N. : Meter Size :