§ 3. COMMERCIAL, INSTITUTIONAL/GOVERNMENTAL, AND INDUSTRIAL SEWER CONNECTION APPLICATION.

To the City of Grayville:

A.   THE UNDERSIGNED being the                                                     of the property located    (Owner, Lessee, Tenant, etc.)

   at DOES HEREBY REQUEST a permit to                       an industrial sewer connection
                      (Install, Use)

   serving the                                            which company is engaged in                        

         (Name of Company)

   at said location.

1.   A plat of the property showing accurately all sewers and drains now existing is attached hereunto as Exhibit “A”.

2.   Plans and specifications covering any work proposed to be performed under this permit is attached hereunto as Exhibit “B”.

3.   A complete schedule of all process waters and industrial wastes produced or expected to be produced at the property, including a description of the character of each waste, the daily volume and maximum rates of discharge, and representative analyses, is attached hereunto as Exhibit “C”.

4.   The name and address of the person or firm who will perform the work covered by this permit is                                                                                                       .

B.   In consideration of the granting of this permit THE UNDERSIGNED AGREES:

1.   To furnish any additional information relating to the installation or use of the industrial sewer for which this permit is sought as may be adopted in the future.

2.   To operate and maintain a control manhole and any waste pretreatment facilities, as may be required as a condition of the acceptance into the public sewer of the industrial wastes involved in an efficient manner at all times, and at no expense to the city.

3.   To cooperate at all times with the Grayville City Council, and their representative in their inspecting, sampling, and study of the industrial wastes, and any facilities provided for pretreatment.

4.   To notify the Grayville City Council immediately in event of any accident, negligence, or other occurrence that occasions discharge to the public sewers of any wastes or process waters not covered by this permit.

DATE:                                                 SIGNED:                                                     

                        (Address of Applicant)

                                                                                                         (Address of Applicant)

   (Certification by City Treasurer)

$                                       connection fee paid.

$                                       inspection fee paid.

Application approved and permit granted:

DATE:                                              SIGNED:                                                  

                        (Approving Authority)