ReWa Root Control Application Form

All root control applications shall be accompanied by a Root Control Application Form, which shall include the following information:

* Required Fields

* Application Company Name:
Chemical Used:
Truck Tag No.
Volume of Treatment, Number of Gallons	(Raw Material)
Diameter of Pipe Treated
Linear Feet Treated
Neutralization Added	Yes No
Type of Neutralization
Application Site (if more than one location for this treatment, provide same information for other location(s) on new form)
Source	ReWa Sub-District
* Name
* Contact
* Address:
* City:
* State:
* Zip
County:
* Daytime Phone Area Code: Phone:
Alternate Phone Number Area Code: Phone:
Location Description:
Receiving Treatment Facility:
Application Date:
Manhole Numbers (if known):	From: To:
I certify that the above information is correct and that the root control application is from the location listed above. Based on my inquiry of the person(s) who manage the process, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete.
Name of Authorized Company Official:
Title of Authorized Company Official:
E-Mail: