Name:
Company:
Address1:
Address2:
City:
State:
Zipcode:
Phone:
Email Address:
Type of System:
Location of System - County:
Address1:
Address2:
City:
State:
Watershed:
GPS Coordinates:
System Operator:
Contact Name:
Phone:
Email:
Responsible Management Entity (RME):
Contact Name:
Phone:
Email:
How long has the current RME been operating the system?
When did the system become operational?
What agency issued he permit?
Is the system currently operating under a permit?
Does this system have a surface or subsurface discharge? (Surface - any system designed to be treated, disinfected and discharged into a receiving body of water; subsurface - any system designed to use a collection vessel to discharge into the soil)
How many homes and/or businesses are connected to the system?
This systen was desiged for a flow of:
Is the system meeting effluent parameters as set out by permit?
Is the system experiencing any problems?
Is there a full time operator for the system?
How many employees are employed for the system?
How many hours a week is required to operate and maintain (ex:check pumps, clean screens, collect monitoring data,etc) the system?
If you have a septic tank or tanks at individual homes as part of your system, how often do you have them pumps?
Who maintains the system?
How was the system funded? (select all that apply)
Average monthly cost per household?
Average monthly cost per business?
Additional demographic information you are able to provide such as median income for those served, # users, etc.
Additional comments/information:
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