Concrete and/or Masonry Contractors
Clean Water Business Partner Survey

In the course of providing services, some businesses generate wastewater.  If properly dealt with, this is not a problem.  When wastewater is disposed of improperly into the storm drain system, pollutants go directly into our waterways with no treatment.

Clean Water Business Partners make a commitment to properly dispose of their wastewater.  By doing this, they help to ensure that future generations can use and enjoy our most valuable natural resource...water!  Join the City of Chico and Butte County in a Clean Water Business Partnership, and receive promotional benefits!
Number of Employees:____________________  Years of Business:______________
1. What types of materials do you use?  (Check all that apply)     

☐ Portland cement    ☐ Sand    ☐ mortar    ☐ Supplementary Cementitious Materials    

☐ Colored Concrete    ☐ Dyes      ☐ Sealants	☐ Pervious concrete     ☐ Aggregate particles    

☐ Hydration stabilizing admixtures    ☐ Water-reducing admixtures     ☐ Retarders

☐ Viscosity modifying admixtures   ☐ Internal curing admixtures     ☐ Reinforcing steel

☐Air-entraining admixtures    ☐ Plastic sheeting
		
☐ Other (describe) ___________________________________________________________
___________________________________________________________________________

2.  What types of equipment do you use?  (Check all that apply)  
    	
☐ Truck mounted unit    ☐ Batching Plant    ☐ Portable Unit    ☐ Vacuum	☐ Portable berm    

☐ Power saw   ☐ Water jet   ☐ Spin jet    ☐ Vacuum recovery system    ☐ Core Drill	 

☐ Hammer Drill    ☐ Heater    ☐ Screed	 ☐ Laser Screed   ☐ Surface prep tool

☐ High cycle vibrator    ☐ Shovel    ☐ Groover    ☐ Trowel    ☐ Chute Tool	

☐ Compaction equipment
		
☐ Other (describe) ___________________________________________________________

3. What types of techniques do you use?  (Check all that apply)      

☐ Stamped concrete    ☐ Epoxy terrazzo	    ☐ Spray top    ☐ Acid etch staining

☐ Stenciled concrete    ☐ Water blasting surface preparation   ☐ Hydro-demolition

☐ Abrasive cutting	☐ Exposed Aggregate	☐ Other (describe) __________________

4. How long is the time period between batching and discharge?____________________

5. Do you use and/or produce pervious concrete?________________________________

6.  On a typical day, how many jobs does an operator complete?

☐ 1		☐ 2		☐ 3		☐ 4 		☐ 5		☐ _______

7.  What types of cleaning methods do you use on your equipment? (Check all that apply)      

☐ Application of strong vibrational force    ☐ Prevention of build-up in mixer trucks/portable unit    

☐ Water only    ☐ Water and soap    ☐ Acid wash    ☐ Wet sand blast    ☐ Vacuum recovery  
	
☐ Other cleaning methods (describe) ____________________________________________
__________________________________________________________________________

8.  What precautions do you take to prevent pollutants from entering the storm drain system?
(Check all that apply)      

☐ Dry cleanup (sweeping, absorbents)	☐ Block storm drain    ☐ Cover stock piles	 

☐ Keep stock piles off ground	☐ Use of berms   ☐ Containment   ☐ Washout

☐ Screened      ☐ Collection  	
		
☐ Other precautions (describe) _________________________________________________
__________________________________________________________________________

9.  How do you currently dispose of wastewater generated during cleaning on site?  
(Check all that apply)      

☐ Landscaping/unpaved area	☐ Gutter, street, stormdrain     ☐ Evaporation

☐ Sanitary sewer	 ☐ Hazardous waste disposal      ☐ Approved washout facility

☐ Transport wastewater for discharge off-site.  Where? ____________________________________________________________

☐ Other disposal methods (describe) ____________________________________________
__________________________________________________________________________

10.  What type of training do you and your employees receive regarding wastewater containment and disposal?  (Check all that apply)  

☐ On-site teaching and demonstrations

☐ Workshop and/or seminars provided by parent corporations/ literature and brochures

☐ None

☐ Other ___________________________________________________________________

11.  How would you classify the majority of chemicals you use for Concrete/Masonry?

☐ Rated 1 or 2, biodegradable and/ or environmentally friendly

☐ Rated 3, medium harsh

☐ Rated 4 or 5, harsh

12.  Are you affiliated with any professional organizations? ___________________________

☐ List ______________________________________________________________

13.  Would you be willing to be recognized as a Clean Water Business Partner?

☐ Yes			☐ No

By signing this form you agree that the information you provide on this form is true and correct.

__________________________________________	________________________
Signature					Date
	
____________________________________________________________________
			Print name and name of Business

The Clean Water Business Partnership Program is funded by the City of Chico.