Required fields are marked with asterisks (*)

Welcome

This form is required to be submitted within 30 days of receiving notification from City of Grand Rapids.
Questions regarding survey – contact the Industrial Pretreatment Program at 456-3633

Name of Business

Facility Address

Date

Company Official

Permit Number

Do you have contamination of soil or groundwater due to releases from (Please check all that apply)

Electroplating/metal finishing processes

The coating/treatment of paper or packaging products

Textile

Leather or fabric treating

Leather tanning operations

The manufacturing of PTFE coating or other FFAS sources

None of the above

Please describe below

Has your facility had a fire in which AFFF (Class B) foam was utilized or has firefighter training occurred on your site using AFFF foam?

Yes

Please describe the scenario

Have you analyzed your groundwater for PFAS?

Yes

Please type the results or upload PDF

Results PDF

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Do you have an ongoing groundwater cleanup or investigation?

Yes

Please describe

Reduction/Elimination Actions (List steps taken by your facility to reduce/eliminate PFAS pollutants in your effluent.) Type "NA" if no actions taken.

Attach additional documents explaining actions taken by your facility.

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