8100 Warden Avenue
Markham, ON L6G 1B4
Tel: (905) 475-4862 Fax: (905) 479-7772
Email:[email protected]
ENVIRONMENTAL SERVICES
DEPARTMENT
INFORMATION REQUEST FORM
*** Please fill out ALL FOUR sections ***
NOTE: If your property has multiple tenants with different business activities, please complete this Information Request Form for each tenant
PROPERTY OWNER
Company Name: _____________________________________________________________________________________________
Contact Person Name: _________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Street Address
Unit
City
Province
Postal Code
Phone: __________________ Fax: ___________________ Other Phone: ________________ E-mail: _________________________
TENANT
Company Name: _____________________________________________________________________________________________
Contact Person Name: _________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Street Address
Unit
City
Province
Postal Code
Phone: __________________ Fax: ___________________ Other Phone: ________________ E-mail: _________________________
PRIMARY CONTACT FOR BACKFLOW PREVENTION PROGRAM
Check if same as Property Owner: □
Check if same as Tenant:
□
Company Name: _____________________________________________________________________________________________
Person Name: _______________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Street Address
Unit
City
Province
Postal Code
Phone: __________________ Fax: ___________________ Other Phone: ________________ E-mail: _________________________
TYPE OF BUILDING OR FACILITY
LIST MAIN BUSINESS ACTIVITIES
Please select one or more types from the attached list:
Main business Activities:
_____________________________________________________
________________________________________________
_____________________________________________________
________________________________________________
_____________________________________________________
________________________________________________
If your building/facility type is not listed, please indicate it below:
________________________________________________
_____________________________________________________
________________________________________________
FULL DISCLOSURE REQUIRED: This form is intended to assist the City of Markham in implementing the Backflow Prevention Program. It is the
responsibility of the owner or building occupant to bring to the attention of the City of Markham the building type and business activities.
Owner/Tenant Signature:
The personal information collected herein is subject to the Municipal Freedom of Information and Protection of Privacy Act. The information is collected under the authority of
the City of Markham By-law 2012-27 and may be used for the enforcement and administration of the By-law, and will be stored by the City for such period of time which
facilitates the enforcement and administration of the By-law. Completion of this form constitutes consent by the owner/tenant to these terms and uses, unless otherwise
modified or revised in writing and delivered to the Director of Environmental Services for the City of Markham.
LIST OF BUILDING/FACILITY TYPES
1
Agricultural/Landscaping Applications
38
2
Aircraft Manufacturing
39
Fire Protection Systems with
Auxiliary Water Supply
Fish Farms or Hatchery
3
Airport
40
4
Allied Services to Manufacturing
5
75
Nonferrous Metal Manufacturing
76
Nursing Home
Food Processing Plant
77
Other Metal Container Manufacturing
41
Fuel Dispensing Facility
78
Paint Manufacturing Plant
Analytical Laboratories
42
Funeral Home/Cemetery
79
Penitentiary
6
Animal Feed Lot
43
Garbage Transfer Facility
80
Personal Care Products Manufacturing
7
Animal Shelter
44
Gas Stations
81
Petrochemical Manufacturing
8
Animal Stock Yard
45
Golf Course
82
Petroleum Processing or Storage Facility
9
Apartment Building
46
Greenhouses
83
Pharmaceutical Manufacturing Facility
10
Aquaculture Farm
47
Grocer
84
Photo Processing Facility
11
Asphalt Plant
48
Hair Salon
85
Plants Using Radioactive Material
12
Auto Body Shop
49
Hospital
86
Plastic Manufacturing Plant
13
Auto Dealership
50
Hotel/Motel
87
Plastic Material & Resin Manufacturing
14
Automobile Manufacturing
51
Industrial and Institutional Premises
88
Plating Shop
89
Poultry Farm
15
Automotive Repair
52
Irrigation System
(Without Chemical Addition)
16
Automotive Repair Shop
53
Irrigation System
(With Chemical Addition)
90
Power Generating Facility
54
Kennel
91
Premises Where Access is Prohibited
55
Laboratory
92
Printed Circuit Board Manufacturing
18
Beverage Processing Plant
(Brewery/Distillery)
Blood Clinic
19
Campsite
56
Laundry (Commercial)
93
Printing Plant
20
Campsite with RV Hook-Ups/Dump-Stations
57
94
Pulp and/or Paper Plant
21
Carpet Cleaners
58
95
Radiator Shop
22
Carwash
59
Laundry (Commercial, Coin-Operated)
Lubricating Oil & Grease
Manufacturing
Machine Tool Manufacturing
96
Recycling Facility
23
Chemical Plant
60
Machine Tool Operations
97
Rendering Facility
24
Church
61
Manufacturing Plant (Not Specified)
98
Research Building
25
Clinical Laboratories
62
Meat Packing Plant
99
Restaurant
26
Commercial Premises
63
Medical Clinic (Non Surgical)
100
Rubber Manufacturing
27
Concrete Plant
64
Medical Clinic (Surgical)
101
Sauna & Massage Centre
28
Cosmetic Product Manufacturing
65
Medical Laboratories
102
School (Elementary & High School)
29
Death Care Services
66
Metal Can Manufacturing
103
Slaughter House
30
Dental Office
67
Metal Coating, Engraving
104
Soap & Detergent Manufacturing
31
Dental Surgery Facility
68
Metal Fabrication
105
Steel Manufacturing Plant
32
Dry Cleaning Plant
69
Metal Window & Door Manufacturing
106
Swimming Pool Facility
33
Dye Plant
70
Milk Processing Plant
107
Textile Manufacturing/ Processing
34
Exhibition Ground
71
Mobile Home Park
108
University
35
Farm
72
Mortuary or Morgue
109
Veterinary Clinic
36
Film Processing Facility
73
Motel
110
Veterinary Hospital
37
Fire Protection Systems with Antifreeze, Foam
Injection, and/or Other Chemical Additives
74
Motorcycle Repair Facility
111
Wineries
17