Wastewater Division

1. GENERAL INFORMATION
Name of Facility    

Contact Person      

Physical Address   

Mailing Address      
Note: Please include City, State, and Zip Code.

Phone Number        

Fax Number            

E-mail Address      

2. OWNERSHIP
Owner Name               

Contact Person           

Mailing Address          
Note: Please include City, State, and Zip Code.

Phone Number            

Fax Number                

Owner E-mail Address 

3. FACILITY TYPE
Facility Type   Apartment/Condominium/Townhome Hotel/Motel Shopping Center Other

If Other, please specify 

4. TYPE OF CONNECTION TO PUBLIC SEWER SYSTEM:

Connection Type   Private Lift Station Gravity Line

5. NAME AND ADDRESS OF CONTRACTOR FOR MAINTENANCE.

6. MAINTENANCE FREQUENCY OF PRIVATE SEWER SYSTEM
Lift Station (Check pumps, clean float ball system and remove trash and debris to include grease:   Jet and Clean Sewer Lines

7. ADDITIVES
Are bacteria, enzymes, or other additives being used as oil and grease management tools?    yes no 

If yes, describe types used:

8. CERTIFICATION STATEMENT
By typing your name in the box provided below, you are certifying that the information provided for the Private Sewer Maintenance Survey, to the best of your knowledge, is accurate and complete. You understand this Survey serves as the application for issuance of the Registration Certificate for the City of Orlando Private Lift Station Management Program.  You further understand that falsification of this information is a violation of the City of Orlando Code, and as such, become subject to enforcement actions and penalties as set forth in the City Code.

 Type name here
*Note: This is a required field.