Industrial Waste Management Division

 Industrial Wastewater Permit Refund Claim Form

Instructions:

The following instructions explain how to DOWNLOAD THE FORM for a Claim For Refund for less than $5,000.

This online Claim for Refund Form is only for Industrial Wastewater Permits.

After a claim is successfully downloaded, the Claimant is required to print a copy of the claim, complete and sign it, and mail it to:

City Clerk
Room 395, City Hall
Los Angeles, CA 90012

Customer should provide all documents supporting the refund request such as:

• A copy of the permit
• Any receipt that shows the payment(s) made.
• Any other applicable documents.

Should you have any question regarding the status of an existing Claim, you can call the Billing and Surcharge at (323) 342-1518.

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