Lake Havasu City, AZ · Mohave County
Industrial Waste Questionnaire
Businesses complete and submit this questionnaire to describe their operations and wastewater to Lake Havasu City’s Wastewater Division.
What this form is
The Industrial Waste Questionnaire collects information about a company, its business activities, wastewater types and volumes, discharge destinations, and employee shifts. The form says the city may use the information to issue a discharge permit if one is required. An authorized company official must review and sign the completed questionnaire.
Who needs it
A company operating a facility that generates wastewater completes this questionnaire for Lake Havasu City’s Wastewater Division.
How to submit it
Return the completed document to Lake Havasu City, Wastewater Division, ATTN: Jason Semmens, Industrial Waste Inspector, 1150 McCulloch Blvd N, Lake Havasu City, AZ 86403.
About notarization
This document is signed without a notary; the authorized official signs and dates it, with a seal only if applicable.
How to submit this form
- 1
Download The Questionnaire
Download the Industrial Waste Questionnaire PDF.
- 2
Complete The Form
Enter company and contact information, describe facility activities, and report wastewater and employee shift details.
- 3
Review And Sign
Have an authorized company official review the information, then sign and date the questionnaire.
- 4
Return The Questionnaire
Send the completed document to the Wastewater Division at the address provided on the form.
Frequently asked questions
- Do I need a notary for the Industrial Waste Questionnaire?
- No. An authorized company official signs and dates the questionnaire; a seal is indicated only if applicable.
- How do I submit the Industrial Waste Questionnaire?
- Return it to Lake Havasu City’s Wastewater Division, addressed to Jason Semmens, Industrial Waste Inspector, at 1150 McCulloch Blvd N, Lake Havasu City, AZ 86403.
- What information does the questionnaire ask for?
- It asks for company and contact details, business activities, wastewater types and volumes, discharge destinations, waste hauler information if used, spill-plan status, and employee shift details.
Need something notarized?
This Industrial Waste Questionnaire doesn’t need a notary — but if you have another Lake Havasu City form that does, a commissioned online notary can help.