Calculations

FATS, OIL, GREASE (FOG) REGISTRATION FORM

SECTION I- GENERAL INFORMATION

A. Name of Establishment

B. Full Physical Address

Street Address

City

State

Zip

C. Mailing Address (if different)

Street Address

City

State

Zip

Name of Establishment Owner

Establishment Phone Number

Environmental-related permits held for this facility/location (Air, Storm water, Waste water, etc.)

Health Department Permit

SECTION II- FACILITY OPERATIONAL CHARACTERISTICS

Please check all of the descriptions in the box below that represent your facility.

Type of Food Service Establishment

Location Type

Please indicate each item that you currently have in your facility. (If more than 1, please note in the comments section)

Food Processing Equipment

Calculations

Kitchen Equipment

SECTION III- FOG MANAGEMENT

J. Please provide us with information on your facility's use of the following devices to manage FOG. (Please indicate N/A where appropriate)

Solids Interceptor (In-sink device to accumulate larger particles)

Size of Interceptor(s)

Flow Through Rating (In Gallons per Minute)

Location of Interceptor(s)

How often are interceptors cleaned?

How is FOG from this device disposed?

Are copies of service records maintained?

How long are Service Records kept on file?

Interior Grease Trap(s) (Typically mounted under counter or in floor)

Size of Interceptor(s) (In Gallons or Pounds)

Flow Through Rating (In Gallons per Minute)

Location of Interceptor(s)

How often are Interceptor(s) serviced or cleaned?

Is the service and cleaning handled by the staff of the establishment or by an outside company? If handled by an outside company please state the name of the company handling service or cleaning of Interceptor(s).

How is FOG from this device disposed?

Are copies of Service Records maintained?

How long are Service Records kept on file?

Exterior Grease Interceptor(s) (External system to process water discharged from operation)

Size of Interceptor(s) (In Gallons or Pounds)

Flow Through Rating (In Gallons per Minute)

Location of Interceptor(s)

How often are Interceptor(s) pumped or cleaned?

Name of company handling pumping or cleaning of Interceptor(s)

How is FOG from this device disposed?

Are copies of Service Records maintained?

How long are Service Records kept on file?

Exterior Grease Hopper (Outdoor tank used to dispose of used cooking oil.)

Size of Interceptor(s) (In Gallons or Pounds)

Flow Through Rating (In Gallons per Minute)

Location of Interceptor(s)

How often are Interceptor(s) pumped or cleaned?

Name of company handling pumping or cleaning of Interceptor(s)

How is FOG from this disposed?

Are copies of Service Records maintained?

How long are Service Records kept on file?

SECTION IV- BEST MANAGEMENT PRACTICES

K. What Best Management Practices are used in your facility in regard to the handling of Fat, Oil, and Grease?

SECTION V- CONTACT INFORMATION FOR THIS REGISTRATION

Local Management contact for this establishment